maternal and fetal representations, dimensions of

MATERNAL AND FETAL REPRESENTATIONS, DIMENSIONS OF

PERSONALITY, AND PRENATAL ATTACHMENT IN WOMEN HOSPITALIZED

WITH HIGH RISK PREGNANCY

APPROVED BY SUPERVISORY COMMITTEE

Chair: H. M. Evans, Ph.D.

Wayne H. Denton, M.D., Ph.D.

Sandra Pitts, Ph.D.

Richard Robinson, Ph.D.

C. Allen Stringer, M.D.

DEDICATION

To mothers and babies everywhere, including mine,

and to David.

MATERNAL AND FETAL REPRESENTATIONS, DIMENSIONS OF PERSONALITY,

AND PRENATAL ATTACHMENT IN WOMEN HOSPITALIZED

WITH HIGH RISK PREGNANCY

by

ANNA RACHEL BRANDON

DISSERTATION

Presented to the Faculty of the Graduate School of Biomedical Sciences

The University of Texas Southwestern Medical Center at Dallas

In Partial Fulfillment of the Requirements

For the Degree of

DOCTOR OF PHILOSOPHY

The University of Texas Southwestern Medical Center at Dallas

Dallas, Texas

June 2006

Copyright

by

Anna Rachel Brandon, 2006

All Rights Reserved

ACKNOWLEDGMENTS

Dr. Monty Evans told me the idea for research at Baylor on attachment was

conceived in a conversation he and Dr. Allen Stringer had after an inspiring presentation by

Dr. Linda Mayes a few years ago. When it became time for them to implement the project, I

happened to be a graduate student in the right place at the right time. I am ever grateful for

the trust they had in me, and for their continued support throughout the project.

I approached the dissertation process with the traditional angst, but each member of

this committee has done their utmost to help me through it. Together, Dr. Evans and Dr.

Sandy Pitts have been my “secure base,” continually encouraging me to stretch academically

and clinically. Dr. Evans’ office door was always open to me, and his confidence in me took

over when my own confidence failed. Dr. Pitts poured over articles to help me develop my

research questions, and tirelessly scored ORI’s so we would have two raters. She has also

modeled for me an amazing ability to laugh, even in the most stressful times. Dr. Richard

Robinson generously plowed into a project already in action, helped us make the necessary

corrections, and patiently guided me through the statistical mazes I had been dreading. Dr.

Wayne Denton was always understanding and ever encouraging, and never minded my

bouncing between his important Couples project and my work at Baylor. Dr. Stringer not

only made available the Baylor population for our work, but made possible my additional

training at Yale to ensure a high-quality project. I cannot conceive of any better team of

advocates and collaborators.

My classmates, Paula Miltenberger and Dana Broussard, have made significant

contributions to this work as well. Paula took the lead as the work was initiated here at

Baylor, and continued to invest in the project even while on bedrest during her own

complicated pregnancy. Dana joined us in the midst of chaos, rolled up her sleeves, and was

ever alert to new ways to streamline our operations or minimize data loss. We three could

never have kept up with the volume of work without three amazing volunteers. Daria Dato

was a key team member as we began planning the project, and continued to work through our

first six months of data collection, always willing to take on any task we needed done. Missy

Heusinger and Georgina Rangel also played valuable roles in the data collection and day-to-

day needs of our research. I am grateful to all of them.

On a personal front, my husband David has become the neighborhood hero. He did

the laundry, the shopping, the housework, and guarded my time with vigilance. David

seemed to always know when I could work a little harder, and when I needed to stop. He

believed I could do this work, and he placed its importance over his own needs. If a

dissertation could have a “producer,” he would be mine. All five of our children have

supported my continued education, even though it meant I could not always be there for them

in the way I would have liked to be. And my three beautiful grandchildren are too young to

know what this is that has kept me cloistered in the back of our home for so long, but they’ve

been there to lift my spirits or make me take a break.

Aside from the valuable education I have received, my life is richer for knowing and

working with all of these people.

MATERNAL AND FETAL REPRESENTATIONS, DIMENSIONS OF PERSONALITY,

AND PRENATAL ATTACHMENT IN WOMEN HOSPITALIZED

WITH HIGH RISK PREGNANCY

Publication No.

Anna Rachel Brandon, Ph.D.

The University of Texas Southwestern Medical Center at Dallas, 2006

H. M. Evans, Ph.D.

The present study investigated the effects of self-criticism, dependency, object representation, and risk upon maternal antenatal attachment in women hospitalized during pregnancy with high risk of maternal or fetal demise. Ninety-one women completed the Depressive Experiences Questionnaire (Blatt, D’Affliti, and Quinlan, 1976), the Object Relations Inventory (Blatt et al.,1992), the Maternal Antenatal Attachment Scale (Condon, 1973), the Edinburgh Postpartum Depression Scale (Cox, Holden, and Sagovsky, 1987) and the Center for Epidemiological Studies Depression Scale (Unauthored, 1999) within the first three days of hospital admission. No relationship was indicated between maternal representations and antenatal fetal attachment, nor was there a correlation between maternal representation and fetal representation. Self-critical mothers significantly scored lower in the measure of antenatal attachment quality and endorsed a higher number of depressive symptoms. Mothers hospitalized because of maternal risk were not significantly different in their reports of attachment than were mothers hospitalized because of fetal risk, and no significant differences were found across severity of risk factors as evaluated by the Hobel Risk Assessment. Consistent with previous research, depressive symptomatology was associated with a lower quality of maternal antenatal attachment overall. Results suggest that maternal narratives may not be significantly linked with reported antenatal attachment and depressive symptoms have a stronger association with reductions of antenatal attachment than dependent or self-critical tendencies.

vii

TABLE OF CONTENTS List of Definitions 2 Chapter One: Introduction 4 History of Attachment Theory 4 The Conceptualization of Prenatal Attachment 8 The Measure of Prenatal Attachment 12 Criticism of the MFA Construct 16 The Relevance of Prenatal Attachment 18 Purpose of the Study 23 Chapter Two: Review of the Literature 25 Search Methods 26 Internal Working Models 26

Background 26 Integration of Theory 29 MFA and Object Representation 31

The Contribution of Personality 39 The Impact of Risk 46 Conclusion of Review 54 Rationale 54 Aims 56

Hypotheses 56 Primary Hypotheses 56 Secondary Hypotheses 57 Chapter Three: Methodology 59 Participants 59 Methods and Procedures 59 Measures 60 Chapter Four: Results 66 Demographic Information 66 Overview of Statistical Analyses 68 Chapter Five: Conclusions and Recommendations 84 Characteristics of the Sample 85 Discussion of Findings 89 Theoretical Implications 100 Clinical Implications 100 Limitations and Future Directions 102 Conclusion 105

viii

PRIOR PUBLICATIONS

Brandon, A. R.; Pitts, S.; Robinson, R.; Stringer, C.A. (2006). “Preliminary findings on the

associations of object representation and personality with prenatal attachment during high-

risk pregnancy.” Presented at the Winter 2006 Meeting of the American Psychoanalytic

Association, New York City.

Denton, W. & Brandon, A. R. (2006). Couple therapy in presence of mental disorders. Journal of

Couple and Relationship Therapy, In Press.

McCullough, M. M.; Orsulak, P.; Brandon, A.; & Akers, L. (2005). Rumination, fear and cortisol:

An in vivo study of interpersonal transgressions. Health Psychology, In Press.

ix

LIST OF FIGURES

Figure 1 108 Levels of Mother Narrative Conceptual Level Across Low, Medium, and High Quality of Attachment Scores

Figure 2 109

Levels of Mother Narrative Conceptual Level Across Low, Medium, and High Intensity of Attachment Scores

Figure 3 110

Quality of Attachment and Mother Narrative Conceptual Level Figure 4 111

Intensity of Attachment and Mother Narrative Conceptual Level Figure 5 112

Global Attachment and Mother Narrative Conceptual Level Figure 6 113

Distribution of Levels of ORI Narrative Conceptual Level Figure 7 114

Attachment Style Based on Below and Above Means of MAAS Quality and Intensity Factors Figure 8 115

Distributions of ORI Conceptual Levels of Mother Narrative Across DEQ Self-Criticism Scores Figure 9 116

Distributions of ORI Conceptual levels of Mother Narrative Across DEQ Dependency Scores Figure 10 117 Type of Risk and MAAS Global Attachment Scores Figure 11 118 Type of Risk and MAAS Intensity of Attachment

x

LIST OF TABLES

Table One 119 Demographic Characteristics of Total Sample Table Two 122 Pregnancy Characteristics of Sample Table Three 123 Psychiatric Characteristics of Sample Table Four 124 Means and Standard Deviations of Measures Table Five 126 Means and Standard Deviations of the Object Relations Inventory Mother Narrative for Global Attachment Above and Below the Mean Table Six 127 Means and Standard Deviations of the Object Relations Inventory Mother Narrative for Global Attachment by Standard Deviation Table Seven 128 95% Confidence Intervals of Pairwise Differences in Mean Changes Of Attachment Quality (MAAS) by Conceptual Level of ORI Mother Narrative Table Eight 129 95% Confidence Intervals of Pairwise Differences in Mean Changes Of Attachment Intensity (MAAS) by Conceptual Level of ORI Mother Narrative Table Nine 130 Frequency Distribution of Conceptual Levels of Mother and Baby Narrative Table Ten 131 Spearman’s rho Correlations for Conceptual Level and Attachment Table Eleven 132 Two-Way Contingency Table of Levels of Object Representation Of Mother and Quality of Attachment Above and Below the Mean

xi

Table Twelve 133 Two-Way Contingency Table of Levels of Object Representation Of Mother and Quality of Attachment by Standard Deviation Table Thirteen 134 Two-Way Contingency Table of Levels of Object Representation Of Mother and Intensity of Attachment Above and Below the Mean Table Fourteen 135 Two-Way Contingency Table of Levels of Object Representation Of Mother and Intensity of Attachment by Standard Deviation Table Fifteen 136 Means and Standard Deviations on Dimensions of the Object Relations Inventory for Global Attachment Above and Below the Mean Table Sixteen 137 Means and Standard Deviations on Dimensions of the Object Relations Inventory for Global Attachment by Standard Deviation Table Seventeen 138 Spearman’s rho Correlations for Object Representations of Mother and Baby Narratives Table Eighteen 139 Two-Way Contingency Table of ORI Conceptual Level of Mother Narrative by Baby Narrative Table Nineteen 140 Pearson Product-Moment Correlations of Dependency, Self-Criticism, and Maternal Antenatal Attachment Table Twenty 141 Two-Way Contingency Table of Self-Criticism (Low, Average, and High) and Antenatal Attachment Style Table Twenty-one 142 Two-Way Contingency Table of Self-Criticism (Above and Below the Mean) and Antenatal Attachment Style Table Twenty-two ` 143 Two-Way Contingency Table of Dependency (Low, Average, and High) and Antenatal Attachment Style

xii

Table Twenty-three 144 Two-Way Contingency Table of Dependency (Above and Below the Mean) and Antenatal Attachment Style Table Twenty-four 145 Two-Way Contingency Table of Self-Criticism (Low, Average, and High) and Conceptual Level of Mother Narrative Table Twenty-five 146 Two-Way Contingency Table of Dependency (Low, Average, and High) and Conceptual Level of Mother Narrative Table Twenty-six 147 Two-Way Contingency Table of Object Representation and Self- Critical Characteristics (Below the Mean and Above the Mean) Table Twenty-seven 148 Two-Way Contingency Table of Object Representation and Dependent Characteristics (Below the Mean and Above the Mean) Table Twenty-eight 149 Hobel Risk Assessment Factors Identified as Fetal Table Twenty-nine 150 Hobel Risk Assessment Factors Identified as Maternal Table Thirty 151 Means and Standard Deviations of MAAS Global Antenatal Attachment Scores Across Three Types of Risk Table Thirty-one 152 Means and Standard Deviations of MAAS Global Antenatal Attachment Scores Across Two Types of Risk Table Thirty-two 153 95% Confidence Intervals of Pairwise Differences in Mean Changes MAAS Attachment Intensity by Type of Risk Table Thirty-three 154 Two-Way Contingency Table of Three Risk Types and Antenatal Attachment (MAAS)

xiii

Table Thirty-four 155 Two-Way Contingency Table of Three Risk Types and Maternal Antenatal Attachment Table Thirty-five 156 Pearson Product-Moment Correlations for Severity of Risk and Maternal Antenatal Attachment Table Thirty-six 157 95% Confidence Intervals of Pairwise Differences in Mean Changes MAAS Attachment Intensity by Level of Risk Table Thirty-seven 158 Pearson Product-Moment Correlations for Gestational Age and Antenatal Attachment Table Thirty-eight 159 Pearson Product-Moment Correlations for Depressive Symptoms, Attachment, and Risk Table Thirty-nine 160 Correlations Between Major Demographic Variables, Depressive Symptoms (EPDS), and Antenatal Attachment (MAAS) Table Forty 161 95% Confidence Intervals of Pairwise Differences in Means of EPDS (Depressive Symptoms) Table Forty-one 162 Chi-Square Comparison of EPDS Depressive Symptomatology and MAAS Antenatal Attachment Style Table Forty-two 163 Sample Means and Standard Deviations of Standard and Three Alternate Versions of Scoring of the Depressive Experiences Questionnaire Table Forty-three 164 Sample Intercorrelations of Four Scoring Methods of the Depressive Experiences Questionnaire

xiv

Table Forty-four 165 Pearson Product-Moment Correlations of DEQ Dependency, DEQ Self-Criticism, and MAAS Antenatal Attachment Using the McGill Scoring Method Table Forty-five 166 Pearson Product-Moment Correlations of DEQ Dependency and Relatedness with MAAS Antenatal Attachment Table Forty-six 167 Pearson Product-Moment Correlations of MAAS Antenatal Attachment And Rude & Burnham’s Needy and Connectedness DEQ Scoring Method Table Forty-seven 168 Linear Regression Analyses of Dependency and Self-Criticism Scores Predicting MAAS Global Attachment Score Table Forty-eight 169 Spearman’s rho Correlation of ORI Baby Narrative and Gestational Age (Weeks) Table Forty-nine 170 Comparison of Most Common Risk Factors Table Fifty 171 Comparison of the ORI and MAAS Means and Standard Deviations from Two Samples Table Fifty-one 172 Comparisons of Correlations for ORI Mother Narrative and Maternal Antenatal Attachment in Two Samples

xv

LIST OF APPENDICES

Appendix A: IRB Approval 175 Appendix B: Letter of Consent 176 Appendix C: Measures 177 CES-D 178 DEQ 179 EPDS 183 MAAS 185 Chart Review (Hobel) 192 ORI-Mother 194 ORI-Baby 195 Bibliography 196

xvi

LIST OF DEFINITIONS Antenatal—period of gestation also referred to as “prenatal” and “antepartum.”

Antepartum—period of gestation, also referred to as “antenatal” and “prenatal.” Antepartum depression—in this discussion, refers to the onset of a major depressive episode or minor depression during pregnancy. External validity—the extent to which a study’s conclusions can be applied to populations and settings outside those of the study itself. Incidence—the percentage of the population with an illness episode that begins within a given period of time (e.g., during pregnancy or within the first 3 months following delivery). Internal Working Model (IWM)—dynamic mental representations or “templates” constructed by infants of their interpersonal world that shape expectations, responses, and interpretations of interpersonal behavior Major depressive disorder—a type of mood disorder characterized by one or more major depressive episodes. The Diagnostic and Statistical Manual, version IV, Text Revision, (DSM-IV-TR) defines a major depressive episode as a period of at least 2 weeks during which an individual experiences daily disturbance in mood (intense feelings of sadness), or loss of interest in activities that have been pleasurable in the past, and at least four of eight symptoms: (1) hypersomnia or hyposomnia, (2) changes in appetite or loss/gain of weight, (3) psychomotor agitation or retardation, (4) loss of energy (fatigue), (5) feelings of worthlessness or excessive guilt, (6) problems with concentration, (7) loss of interest in sex, and (8) recurrent suicidal thoughts or suicidal attempt. These symptoms must be present most of the day and nearly every day during the 2-week episode, must cause clinically significant distress or impairment in functioning, and must not be the result of the direct physiologic effects of a substance or a general medical condition. Major depressive disorder is not diagnosed if symptoms are attributable to an acute grief reaction; however, it is diagnosed after an acute grief reaction if the syndrome persists for two months or longer. It is not diagnosed if there is a history of manic, hypomanic, mixed episodes, or schizophrenia. Minor depressive disorder—a subthreshold diagnosis with a number of definitions (also referred to as minor depression). This term usually describes one or more episodes of depression lasting two weeks or longer but with fewer symptoms than required for major depressive disorder diagnosis. Multigravida--a pregnant woman who has carried a previous fetus to viability, regardless of outcome.

1

Multipara—a woman who has carried more than one fetus to viability, regardless of whether the offspring were born alive. Multiparity is the condition of having carried one or more fetuses to viability, and multiparous describes a woman who has borne more than one child. Object Representation—A psychoanalytic term referring to the internal mental representational aspects of a significant other person, incorporating both realistic and fantasied characteristics of the relationship. Perinatal—during pregnancy (also referred to as prenatal) and 12 months following delivery. Period Prevalence—the percentage of the population with depression over a specific period of time (e.g., during pregnancy or from delivery to the end of the first six weeks, the first three months, or the first year, etc.). Postnatal—period of time following birth referring to the infant Postpartum—period of time following birth referring to the mother lasting from parturition to 12 months after delivery. Postpartum depression—the DSM-IV-TR defines this as a specific type of major depressive disorder that has an onset of a major depressive episode within 4 weeks after delivery. In this discussion, the term will be expanded to include minor depression. Point Prevalence—the percentage of the population with depression at a given point in time Prenatal—the period of pregnancy from conception to parturition. Primagravida—A woman during her first pregnancy. Primapara—A woman who has been delivered of one infant of at least 20 weeks gestation regardless of its viability, and primaparous describes a woman in the period of time surrounding her first pregnancy. Puerperium—the 6-week period following delivery. Reliability—the extent to which a test, inventory, or scale is consistent in its evaluation of the same individuals Screening instrument—a measure or test utilized to identify an individual with respect to likelihood of having a specific disorder. A screen itself does not provide a diagnosis, however, when positive, indicates that further investigation is necessary to confirm (or disconfirm) the presence of the disorder.

2

Sensitivity—the ability of a measure or test to correctly identify those with a syndrome, calculated as the percentage of true positive values compared to false negative values. Specificity—the ability of a measure or test to correctly identify those who do not have a syndrome, calculated as the percentage of true negative values compared to false positive values. Validity—the extent to which a test, inventory, or scale measures what it is supposed to measure.

3

CHAPTER ONE Introduction

HISTORY OF ATTACHMENT THEORY

John Bowlby, a young volunteer at a school for maladjusted children, was moved by

his experiences with two young boys—one isolated and distant, the other anxious and

clinging (Ainsworth, 1968). Since neither child had a stable mother figure, he wondered if

early family relationships had profound effects upon the personality development of children.

His curiosity and desire to explore this idea, coupled with his rigorous scientific training at

the University of Cambridge, led to a reevaluation of career goals and the decision to become

a child psychiatrist (Bretherton, 1992; Senn, 1977). Subsequent work led to his formulation

of the basic tenets of what is known today as “attachment theory,” a synthesis of elements

from ethology, cybernetics, information processing, developmental psychology, and

psychoanalysis. Bowlby’s original work focused on the infant’s biological need for a

secure early attachment to the mother and the mother’s response, a major conclusion being

that a maturing child’s mental health fundamentally required that “the infant and young child

should experience a warm, intimate, and continuous relationship with his mother (or

permanent mother substitute) in which both find satisfaction and enjoyment” (Fonagy,

2001a; Bowlby, 1951; Bowlby, 1969).

Bowlby conceptualized the attachment system as an evolutionary set of behaviors

related to those of exploration, fear, affection, and caregiving. Regulation of this system,

Bowlby reasoned, was solely biological; he posited that the infant’s primary goal was to

maintain a certain degree of physical proximity to the mother for survival. Bowlby later 4

added to his stance that attachment would include psychological goals on the part of the

developing child and mother, but his insistence that attachment was an independent

behavioral system and not related to unconscious drives was a solid wedge between his

theory and the psychoanalytic theories of his training. Even though this assumption

separated him from the analytic community, key researchers such as Mary Ainsworth, James

Robertson, Rudolph Schaffer, and Christopher Heinicke aligned with him to flesh out the

theory of attachment that is understood today.

Ainsworth, in particular, believed that the infant’s contribution to the attachment

process was more than biological and included his or her own internal appraisal of the

mother’s behaviors (Ainsworth, Blehar, Waters, & Wall, 1978). The “Strange Situation,” a

20-minute laboratory test developed by Ainsworth, was the first attempt to scientifically

capture the activation of attachment system behaviors between mother and child (Ainsworth

et al., 1978). One-year-old children were exposed to two brief separations from their

mothers; the responses of both mother and baby were recorded and became the basis for a

categorical system of attachment that is still in use today. Most of the children in this study

responded to their mothers’ absence with some distress but, at her return, were rather quickly

comforted and returned to their play. These babies were thought to be “securely attached.”

About 25 percent of the babies responded to mother’s return with indifference, a category

named “insecure—anxious avoidant.” Another 15 percent sought proximity to their mothers

but displayed little or no relief from their distress when reunited. This style was also

regarded as insecure, but called “anxious resistant.” The discovery that physical separation

alone could not account fully for infant response took attachment research to a new level.

5

Ainsworth and Bowlby persevered in their investigation of the idea that cognitive

mechanisms underpinned the behavioral components of the attachment system. Bowlby

coined the term “internal working model” to describe a process of mental representation that

the preverbal infant developed of his primary caregiver. In his historical work, Attachment

and Loss: Volume I, Attachment, Bowlby described a child’s “internal world” in this way:

Starting, we may suppose, towards the end of his first year, and probably especially actively during his second and third when he acquires the powerful and extraordinary gift of language, a child is busy constructing working models of how the physical world may be expected to behave, how his mother and other significant persons may be expected to behave, how he himself may be expected to behave, and how each interacts with all the others. Within the framework of these working models he evaluates his situation and makes his plans. And within the framework of the working models of his mother and himself he evaluates special aspects of his situation and makes his attachment plans (1969; pg. 354).

Using this concept, Ainsworth’s infants must have had distinct internal representations of

their mothers and of what separation from her meant. What went unmentioned in

Ainsworth’s original study was her ability to anticipate each infant’s attachment style based

on observations of maternal behavior. Her years of home observations in Uganda had caused

her to suspect a predictive link might exist between maternal responsiveness and security of

infant attachment (Ainsworth & Marvin, 1995). Ainsworth and colleagues subsequently

introduced the concept of “sensitivity” to describe the type of caregiving she found that

correlated with secure attachment on the part of the infant (Ainsworth, Bell, & Stayton,

1974). Mothers who exhibited sensitive caregiving behavior were those able to (a) attune to

infant’s signals with attentiveness, (b) appropriately interpret the signals, (c) respond

appropriately to the signals, and (d) react promptly, in a time period that did not provoke

excessive frustration for the child. Highlighting that central to the internal working model

was the expected availability and response of the attachment figure injected an importance

6

into the actions of the maternal part of the dyad that the previous systemic view of

attachment behaviors had not (Sroufe & Waters, 1977; Bowlby, 1973). Bowlby continued

to refine his approach, further hypothesizing that a child’s internal working model of self

takes a complementary position to the representation the infant has of his caregiver. In the

most primary form of this collaboration, the child evolves a representation of how acceptable

or unacceptable he is by how he feels his caregiver views him. More complex forms of this

transaction appear all through life in self-other relationships (Fonagy, 2001b).

Those who followed Bowlby and his fellow pioneers of theory moved beyond infancy

and began exploring attachment through the internal worlds of young children (Main,

Kaplan, & Cassidy, 1985), adolescents (Kobak & Sceery, 1988), and adults (George, Kaplan,

& Main, 1985). The Adult Attachment Inventory (AAI), developed by George et al.,

consists of a series of open-ended probing questions designed to elicit as many details as

possible about the individual’s childhood attachment experiences and personal evaluations of

the effects those early events have on current life functioning (George et al., 1985). This

enabled researchers to compare adult and child attachment within the same theoretical

framework and categorization strategy. The next wave of research divided adult attachment

into two distinct perspectives: parenting and romantic relationships (Bartholomew & Shaver,

1998; Hazan & Shaver, 1987; Bartholomew & Horowitz, 1991). Moving from the

behavioral level to the representational level allowed the exploration of how early attachment

experiences were remembered by adults as well as how these memories might act as

templates for interpersonal relationships (Main et al., 1985). This has broadened the

application of attachment theory to all stages of life, including an empathic understanding of

7

the emotional significance of death and dying (Kubler-Ross, 1969). In each vein of research,

behavioral, emotional, and cognitive markers have been identified to enable the measurement

of attachment and, since Ainsworth’s first measure, numerous objective and projective

instruments have been developed for examining childhood, adolescent, and adult attachment.

THE CONCEPTUALIZATION OF PRENATAL ATTACHMENT

It is only fitting that theoretical analyses of the experience of pregnancy largely began

with women theorists. Deutch, Bibring, and Benedeck explained prenatal attachment in

psychodynamic terms as a process in which a pregnant woman’s libidinal energy was

cathected into the fetus (Deutch, 1945; Bibring, 1959; Bibring, Dwyer, Huntington, &

Valenstein, 1961; Benedek, 1959; Benedek, 1958). They hypothesized that the fetus

becomes more human to the woman as pregnancy progresses, and eventually the fetus

becomes loved both as an extension of self and as an independent object. While this was

fascinating material, one of the first empirical suggestions that there was some prenatal

connection between mother and fetus came from Kennell and Klaus’ observations of the

intense grief exhibited by mothers of infants who died during birth (Kennell, Slyter, & Klaus,

1970). This team found maternal grief uninfluenced by whether or not the mothers had any

physical contact with the babies after delivery. Additional work by Klaus and others drew

attention to the deleterious effects of early separation between mother and neonate and

introduced ways of enhancing early postnatal attachment (Klaus et al., 1972). These new

ideas launched scientific inquiry by a few key individuals, bringing about the formulation of

the construct of prenatal attachment within both medical and psychological communities.

8

Rubin, a nurse specializing in maternity care doing doctoral work at the University of

Chicago, led the way as she explored women’s attainment of the maternal role, concluding

that the immediate bond between postpartum mother and neonate was a consequence of

prenatal processes (Rubin, 1967; Rubin, 1975). Rubin identified four specific tasks the

women she observed navigated before childbirth: (1) Seeking safe passage for self and baby,

(2) ensuring that the baby is accepted by significant others, (c) binding-in to the fetus, and (4)

giving of herself. These tasks formed a framework for early investigation of the

psychological experience of pregnancy.

Meanwhile, a perinatal epidemiologist in Australia interviewed 30 primagravidas

(first pregnancies) at various time points throughout the three trimesters of pregnancy and

found they were able to conceptualize their babies in an increasingly human way over the

passage of time (Lumley, 1972). The introduction of ultrasound during pregnancy inspired

her to examine the impact on maternal bonding of a visual image of the fetus (Lumley,

1980). Lumley’s findings suggested this early view of the fetus enhanced a mother’s ability

to differentiate it as a “little person.” Her next project was one of the first empirical

longitudinal studies of prenatal attachment. Through the use of simple tape-recorded

interviews at 5 time points before and after childbirth, she attempted to capture first-time

parents’ attitudes of their fetus. She conceptualized attachment as being an “established

relationship with the fetus in imagination,” a point at which mothers thought of their babies

as a “real person” (Lumley, 1982). Lumley reported this phenomenon in 30% of her subjects

in the first trimester, 63% in the second trimester and, by 36 weeks gestation, in 92%. She

9

interpreted delayed attachment as being related to unpleasant symptoms of pregnancy and

lack of interest or support on the part of husbands.

Leifer, a psychologist at the Illinois Institute of Technology, was the author of a

monograph reporting findings from a study of 19 primigravidas on the psychological changes

observed during the course of gestation (Leifer, 1977). She concluded that, while pregnancy

was a time of emotional upheaval and rapid role change, it was also a time of developmental

maturation. Leifer introduced the element of personality into the psychological state of

pregnancy, concluding the degree of personality integration achieved during the first months

of pregnancy could predict psychological growth throughout the rest of pregnancy and into

early motherhood.

While early formations of prenatal attachment came from the psychoanalytic

approach, the study of the concept was carried on in earnest by nurses, often in the process of

graduate work. Mecca Cranley, for example, wrote the first literature review of the subject

as her dissertation, proposing a multidimensional model composed of six aspects of

maternal-fetal attachment she had identified from her research: Differentiation of Self from

Fetus, Interaction with the Fetus, Attributing Characteristics to the Fetus, Giving of Self,

Role Taking, and Nesting (Cranley, 1979). Cranley is also credited with the first formal

definition of the construct of maternal-fetal attachment (MFA): “The extent to which women

engage in behaviors that represent an affiliation and interaction with their unborn child”

(Cranley, 1981).

Muller, a researcher who utilized Cranley’s construct of maternal fetal attachment,

ultimately found this strategy of conceptualizing the phenomenon focused on behaviors to

10

the exclusion of the thoughts and fantasies which also revealed the growing affiliation

between mother and fetus (Muller, 1993). In her dissertation work, she redefined prenatal

attachment as “the unique relationship that develops between a woman and her unborn fetus.

These feelings are not dependent on the feelings the woman has about herself as a pregnant

person or her perception of herself as a mother” (Muller, 1990). An Australian researcher,

John Condon, also found Cranley’s work insufficient in the description of MFA. He went

back to adult attachment theory and proposed Bretherton’s broad view of attachment as an

“emotional tie” or “psychological bond” to a specific object was not only applicable to MFA

but added coherence to the construct (Condon, 1993; Bretherton, 1985). Condon suggested

that antenatal attachment contained the core experience of love, and could be described as a

developing relationship in which the mother seeks “to know, to be with, to avoid separation

or loss, to protect, and to identify and gratify the needs of her fetus.” He later formally

defined prenatal attachment as simply “the emotional tie or bond which normally develops

between the pregnant parent and her unborn child” (Condon & Corkindale, 1997). Now

there were three definitions to the developing construct of prenatal attachment that did not

have much in common.

The most recent conceptualization of prenatal attachment has attempted to combine

these behavioral, cognitive, and emotional approaches with this working definition: “Prenatal

attachment is an abstract concept, representing the affiliative relationship between a parent

and fetus, which is potentially present before pregnancy, is related to cognitive and emotional

abilities to conceptualize another human being, and develops within an ecological system”

11

(Doan & Zimerman, 2003). However, no consistent use of any of these four definitions of

the construct has been noted in recent research.

THE MEASURE OF PRENATAL ATTACHMENT

Cranley developed the first antenatal attachment scale, the Maternal Fetal Attachment

Scale (MFAS), using the six aspects she had conceptualized in her dissertation work

(Differentiation of Self from Fetus, Interaction with the Fetus, Attributing Characteristics to

the Fetus, Giving of Self, Role Taking, and Nesting; Cranley, 1981; Cranley, 1979). She

asked clinicians and childbirth educators to identify statements made by their patients that

implied MFA; the resulting 37 items were then administered to 71 pregnant women between

35 and 40 weeks gestation. Due to a lack of statistical reliability, she eliminated the Nesting

aspect after this pilot of the scale. The resulting 24-item instrument yielded five subscales

and one global measure of maternal-fetal attachment. Having an instrument pushed MFA

research ahead quickly; most previous studies had been qualitative with small samples. The

MFAS gave the field a quantitative measure appropriate for cross-sectional studies of larger

samples (Grace, 1989) and, 25 years after its development, continues to be the instrument

used most frequently by nurse researchers in prenatal studies (Beck, 1999b).

Muller’s personal research utilizing the MFAS and her subsequent 1992 literature

review found no consistent results; in fact, findings were often either inconclusive or

contradictory (Muller & Ferketich, 1992; Muller, 1992). She began to entertain doubt that

Cranley’s five subscales truly captured prenatal attachment, and even wondered if MFA

could be viewed in such a multidimensional fashion (Muller & Ferketich, 1993). Another

12

research team also questioned the theoretical base of the MFAS, as well as its reliability and

validity (Mercer, Ferketich, May, DeJoseph, & Sollid, 1988). The Mercer team made data

from a study on antepartum stress available to Muller, and she conducted a secondary

analysis of the interviews with those participants (Mercer, Ferketich, DeJoseph, May, &

Sollid, 1988). Her findings indicated only three of Cranley’s subscales corresponded with

the categories generated by the interview data, and two (Giving of Self and Interaction with

the Fetus) did not correspond at all (Muller et al., 1992; Beck, 1999a). As Muller suspected,

Cranley’s items were not capturing certain emotional elements Muller documented from the

open-ended interviews of women in the Mercer et al. study (1988). Mercer participants often

made statements about their unborn babies using words like “hope,” “wish,” and “imagine;”

they seemed to be expressing feelings rather than just engaging in behaviors. This analysis

led to the development of a new scale, the Prenatal Attachment Inventory (PAI; Muller,

1990). The 29 items of this instrument were designed to measure affectionate attachment or

the personal relationship that develops during pregnancy between mother and fetus. The

construction reflected Muller’s disagreement with a multidimensional view of MFA and

contained no subscales, providing only a global score. Muller’s intent was for this scale to

emphasize affiliation, exclude behavioral measures, and stand as an adjunct to Cranley’s

MFAS, with the goal of increasing agreement across studies (Muller, 1993). Muller also

conceptualized a new model of attachment in pregnancy, postulating that an expectant

mother’s early experiences with her primary caregiver led to the development of internal

representations, which then influenced subsequent attachments to family, partner, and

13

friends. Ultimately this process enabled a woman to adapt to pregnancy and attach to her

fetus.

Muller’s claim that the MFA construct was unidimensional and her assertion that the

PAI yielded only one global measure was challenged some years later by a research team

with a sample of 171 Swedish women in their third trimester of pregnancy (Siddiqui,

Hagglof, & Eisemann, 1999). Their analysis revealed an underlying dimensional structure

with five identifiable factors representing recurrent themes that accounted for 53.9% of the

variance: Affection, differentiation of self from fetus, interaction, sharing pleasure, and

fantasy. The team proposed that Muller’s measure actually supported a multidimensional

construct of MFA, pointing out several possible explanations for the disagreement. Their

most convincing argument was that Muller’s work had been conducted on women at various

points in their pregnancy, anywhere between 14 and 40 weeks of gestation, while the

Siddiqui et al. team administered the PAI during the third trimester only (between the 36th

and 40th week of gestation). Since literature was abundant with recent findings strongly

indicating that MFA increased through the course of the pregnancy (Cranley, 1981; Grace,

1989; Lerum & LoBiondo-Wood, 1989), Muller’s data was confounded by this variation

(Siddiqui et al., 1999).

The newest instrument on the MFA scene was developed in Australia by John

Condon (Condon, 1993; Condon & Corkindale, 1998). Condon believed that the existing

instruments inadequately differentiated the attitude toward the fetus from the attitude toward

the state of pregnancy and motherhood. He included 19 items in his Maternal Antenatal

Attachment Scale (MAAS), focusing exclusively on thoughts and feelings about the baby

14

and ignoring attitudes about the physical state of pregnancy or the maternal role. Two

factors, “quality” and “intensity,” were generated. “Quality” described the affective

experiences the mother reported, such as closeness/distance, tenderness/irritation,

positive/negative, joyful/unpleasant anticipation, and a vivid/vague internalized

representation of the fetus as a real person. “Intensity” referred to the amount of time she

spent thinking about, talking to, dreaming about, or tactilely interacting with the fetus.

Condon mapped these two factors as perpendicular continuums, forming four quadrants of

attachment style.

One other scale, the Prenatal Maternal Attachment Scale, is mentioned in the

literature, however, only one published study in addition to the initial methodological study

has reported its use (Fowles, 1996; LoBiondo-Wood & Vito-O'Rourke, 1990). 29 items are

designed to be administered at any time during pregnancy, and 10 additional items are

completed only after quickening is experienced.

Of these described instruments, Cranley’s MFAS and Condon’s MAAS are the two

most commonly used measures (Laxton-Kane & Slade, 2002). While it is beyond the scope

of this discussion, it also must be noted that both Cranley and Condon have constructed

paternal adaptations of their measures, hypothesizing that there may be a complementary

paternal-fetal attachment process (Weaver & Cranley, 1983; Condon, 2005). No doubt these

multiple approaches to capturing the attachment process have stimulated the increased

attention and empirical research devoted to MFA, with particular curiosity concerning

relationships between the nature of such attachment and the mother’s early parenting

experiences, her cognitive capacity to develop an internal working model of her fetus, her

15

own adult attachment style, her level of social support, and links to perinatal depression,

anxiety, and postnatal attachment (Cannella, 2005).

CRITICISM OF THE MFA CONSTRUCT

Bowlby’s original theory was built on the premise of reciprocal elements in the

attachment system. Since prenatal attachment can only be investigated through one part

(mother) of this system, some feel that attachment cannot be measured antenatally with any

validity. In addition, the concept of prenatal attachment requires a view of the motivation of

security counter to the original theory of the attachment system. Infant and adult attachment

in the Bowlbian sense had the goal of security seeking; attachment behaviors were triggered

by distress and fear of separation from the attachment figure. In maternal antenatal

attachment the mother provides (or may feel responsible for providing) security for the fetus.

It has been proposed that prenatal attachment is more appropriately viewed as an “emotional

bond” that bears similarities to attachment but is not the same as traditional infant and adult

attachment (Pollock & Percy, 1999). Along this line of thinking, it has been suggested that

prenatal attachment inventories are no more than attitude measures that may be confounded

by social desirability and adjustment (Waters, 2005).

That pre- and post-birth attachments may require different conceptual frameworks is

inarguable; nevertheless, their interrelationship is visible in the consistent attention the

Bowlbian contingent gives to the mother’s own cognitive representations of caregiving and

by viewing the feelings and behaviors related to this internal working model as critical to her

contribution as an attachment figure for her infant. The possibility there is a convergence

16

between MFA and mother-infant attachment is illustrated by the association found between

measures of prenatal attachment and the following: Postnatal attachment style categorization

(Muller, 1996b), parental behavior before and after birth (Condon et al., 1997; Pollock &

Percy, 1999), maternal feelings for the neonate after delivery (Leifer, 1977), feeding behavior

and maternal sensitivity to an infant’s cues, (Fuller, 1990), and postnatal maternal

involvement with the infant (Siddiqui, Hagglof, & Eisemann, 2000). This author suggests

that, in the absence of the infant’s contribution to the matrix (appearance, temperament, etc.),

measuring prenatal attachment may provide an avenue for a purer investigation of factors

that are solely maternal, such as the mother’s own personality, attachment style, and mental

representations of her own early caregiving experiences.

In addition, the issue of reciprocity may be less important if the expectant mother

assigns reciprocity to the fetus in terms of movement and activity. A literature review of

prenatal attachment found that quickening, or discernable fetal movement, was consistently

found to be positively correlated with attachment as measured by questionnaires (Muller,

1992). In one randomized controlled observational study of a sample of 213 women with

uncomplicated pregnancies, fetal movement counting resulted in a statistically significant

increase in total attachment scores on the Cranley scale of maternal-fetal attachment (Mikhail

et al., 1991). Zeanah et al. reported that mothers with higher levels of prenatal attachment

perceived more movement from their fetus’ than those with lower attachment (Zeanah, Carr,

& Wolk, 1990). Additionally, an exploratory study of 26 couples proposed four levels of

parental awareness during the third trimester of pregnancy, one of which was “awareness of

infant interactive ability” (Stainton, 1990). Some participants described their infants as

17

actively participating in communication with them by moving toward abdominal stroking,

extending a limb, or increasing/decreasing activity when certain voices were present.

Lastly, fetal perceptions in utero are largely unknown. Some theorists have

hypothesized that intrauterine experience appears to leave “dim residues” that influence later

preference for open versus closed spaces (Balint, 1959), sleeping positions, and sensory

sensitivities (Piontelli, 1987; Piontelli, 1988). Neonatal research has found that newborns

can recognize their mother on the basis of visual cues alone (Bushnell, Sai, & Mullin, 1989),

by voice (Fifer, 2002), and by odor (Porter, Winberg, & Varendi, 2005). In one older trial,

neonates could produce either the mother’s voice or the voice of another female by sucking

on a nonnutritive nipple in different ways (DeCasper & Fifer, 1980). It is not inconceivable

that, beyond our measurement ability, some intrauterine fetal phenomenon complementary to

MFA takes place. Therefore, without disregarding the issues raised concerning the validity

of prenatal attachment measures, the literature available supports their use in further research

(Beck, 1999c).

THE RELEVANCE OF PRENATAL ATTACHMENT

Bowlby and colleagues illustrated how critical responsive and sensitive caregiving is

for the psychological health of humans from infancy through development, and the

contributions of the others described in this discussion have strongly suggested mothers

develop caregiving capacity through a variety of prenatal processes. As a result, from a

clinical standpoint, the concept of antenatal attachment has facilitated an understanding of

the pregnancy period, as well as an understanding of the emotional cost of the loss of a fetus

18

(Laxton-Kane et al., 2002; Stainton, 1990a; Boyce & Condon, 2000; Condon, 1986; Frost &

Condon, 1996). However, refinements of the theoretical construct tested via hypotheses in

correlational, comparative, and longitudinal designs are sorely needed (Cannella, 2005).

Along with increased empirical knowledge comes responsibility to investigate ways to

identify mothers at risk for poor attachment and interventions that can adequately prepare

women for motherhood. Women unsure of their attachment may respond to appropriate

interventions, and women unaware of or unconcerned about their attachment to their fetus

may benefit from education and motivation (Shieh, Kravitz, & Wang, 2001). While some

interventions promoting prenatal attachment have been introduced, there is much more to be

learned about the concept of attachment, what facilitates its growth, and what prevents or

stifles it (Carter-Jessop, 1981; Carson & Virden, 1984; Mikhail et al., 1991; Cranley, 1992).

Studies of the use of MFA to predict postnatal mother-infant attachment are

inconclusive in light of inconsistent research and the few available longitudinal studies.

Modest correlations have been found between an unpublished measure of attachment and

maternal feelings of attachment 24 hours after delivery (Reading, Cox, Sledmere, &

Campbell, 1984), prenatal psychological functioning and postnatal attachment (Leifer, 1980),

MFAS scores and postnatal maternal interaction (Fuller, 1990), Prenatal Attachment

Inventory (PAI) scores and the Maternal Attachment Inventory (an attitude-based postnatal

measure) (Muller, 1996a), PAI scores and postnatal maternal involvement (Siddiqui &

Hagglof, 2000), MFA and maternal competence (Mercer & Ferketich, 1994), and MFA and

mutuality in family relationships and infant mood (White, Wilson, Elander, & Persson,

1999). These longitudinal studies describing contributors to secure attachment are clinically

19

significant, but also demonstrate how much more work needs to be done in order for a

complete understanding of the impact of MFA quality on the next generation.

A generational quality to attachment is suggested by a benchmark study conducted in

Great Britain with a sample of 100 primagravidas (Fonagy, Steele, & Steele, 1991). On the

basis of AAI classifications given to expectant parents during the last trimester of pregnancy,

the research team was able to predict the Strange Situation category of infant attachment to

parent when the child was 1 year of age. The correlation between parents and babies styles

in the “secure” and “insecure” categories was robust (r = 0.75). This suggests that a parent’s

state of mind in regard to attachment has an enormous effect upon the quality of attachment

of their child (this is not to suggest that significant life events during the first year of life do

not have an effect). These findings stimulated many replication studies with the same link

between secure mothers and secure babies, and insecure mothers and insecure babies

(Levine, Tuber, Slade, & Ward, 1991; Mikulincer & Florian, 1999; Priel & Besser, 2000b).

The implication that we might be able to target families at risk for insecure attachment

provides a new venue for developing interventions to break vicious cycles and foster

healthier attachment.

Attachment theory has also provided another way of conceptualizing the vulnerability

to or etiology of psychopathology. By the publication of his second volume in the

Attachment and Loss series, Bowlby was hypothesizing links between insecure attachment

and particular psychopathologies, such as phobias (Bowlby, 1973). Later prospective studies

by a plethora of researchers have connected insecure attachment with conduct disorders,

parental depression, parental schizophrenia, borderline personality disorder, adolescent

20

suicidal acting-out, and vulnerability to psychopathology in childhood (Brisch, 2002). As

research on attachment disorders continues, new importance is ascribed to early identification

and intervention. Inge Bretherton aptly applies one of Freud’s statements:

So long as we trace the development from its final outcome backwards, the chain of events appears continuous, and we feel we have gained an insight which is completely satisfactory or even exhaustive. But if we proceed in the reverse way, if we start from the premises inferred from the analysis and try to follow these up to the final results, then we no longer get the impression of an inevitable sequence of events which could not have otherwise been determined (Bretherton, 1992; Freud, 1955).

It is an estimable goal to have enough knowledge about the role of MFA to “proceed in the

reverse way,” and endeavor to make the “inevitable sequence of events” in incomplete

mother-child attachment not so inevitable.

Poor attachment has not surprisingly been associated with the painful topic of fetal

and child abuse. A study in England with a sample of 40 women referred by Social Services

departments suggested that “negative preoccupied” antenatal attachment (as measured by the

Maternal Antenatal Attachment Scale) was predictive of an increased likelihood of

symptoms of anxiety, mood disturbance, and depression, self-reported irritation with the

fetus, and even fetal abuse (Pollock & Percy, 1999). Other researchers have looked at the

association between insecure attachment in mothers and the incidence of child abuse and

found positive correlations (Moncher, 1996). Contrastingly, strong MFA has been associated

with positive health practices during pregnancy, such as abstinence from tobacco, alcohol,

and illegal drugs, obtaining prenatal care, healthy diet and sleep habits, adequate exercise,

use of seat belts, and learning about pregnancy, childbirth, and infant care (Lindgren, 2001;

Lindgren, 2003).

21

Quality of attachment has also been associated with the perinatal mental health of the

mother. Weak attachment and negative maternal attitude have been associated with

postpartum anxiety (Blumberg, 1980; Gaffney, 1989) and depression (Condon et al., 1997;

Lindgren, 2001). On the other hand, strong attachment was found to be a moderator of the

vulnerability to postpartum depression in one sample of women in Israel (Priel & Besser,

1999). Personality vulnerability factors to depression were measured, and highly self-critical

women reported less depression when strongly attached to the fetus during pregnancy.

However, as reported in one integrative review, associations between attachment and

psychosocial variables have been disappointing (Cannella, 2005). Methods used across

studies have been inconsistent, psychometric properties of all instruments have not been

consistently valid and reliable, and the relationships investigated were exploratory rather than

theoretical. It was concluded that correlational studies utilizing theory-driven variables are

necessary for more significant findings.

An important factor for consideration is the large gap in existing research with

diverse populations. Psychometric data of current prenatal attachment measures has largely

been established using samples of low-risk, middle-class, American, Caucasian pregnant

women (Shieh et al., 2001). An increasing number of samples of women with high-risk

pregnancies (defined in this work as “fetal anomaly and/or the presence of a chronic disease

or pregnancy-induced disease threatening maternal or fetal health and carrying an increased

chance of mortality for either mother or fetus”) are being included in research, but only a few

published studies have included risk serious enough to require hospitalization (Penticuff,

1982). The reliability and validity of the existing tools for high-risk women is unknown, as

22

are the consequences of risk on parental adaptation and patterns of attachment. In addition to

the health/mortality concerns, high risk pregnancies include the significant possibility of fetal

anomaly and/or extreme prematurity. Extreme prematurity has been associated with a higher

incidence of insecure attachment; ongoing longitudinal work is examining this further, taking

into consideration the neurobiological risk factors (Brisch, 2002).

Finally, the children of societies everywhere deserve mothers (and fathers) prepared

for the awesome challenge of loving and training new humans. Five decades of research has

emphasized that caregiver response is the central element in how a child understands self and

others. John Bowlby expressed this most cogently:

Just as children are absolutely dependent on their parents for sustenance, so in all but the most primitive communities, are parents, especially their mothers, dependent on a greater society for economic provision. If a community values its children it must cherish their parents (Bowlby, 1951).

PURPOSE OF THE STUDY

In line with the recommendations of the works cited, this research will undertake a

theory-driven approach to the study of attachment in a sample of women hospitalized with

high-risk pregnancies. The purpose of this study is to investigate the influence of an

expectant mother’s personality style, her maternal object representations, and her ability to

develop an internal representation of her fetus upon the quality and intensity of maternal fetal

attachment. The exploration of the power of object representation and personality to predict

prenatal attachment in the context of hospitalization during high-risk pregnancy would have

relevance in both intervention and standard of care for such mothers. Since this is a highly

23

specialized sample of individuals, it is expected that other variables may have predictive

value. Prior depressive episodes, current levels of depression, type and severity of maternal-

fetal risk, as well as gestational age of the fetus at the onset of complications will be taken

into account.

The construct of MFA discussed in this work will be identified as suggested by Doan

and Zimmerman: “Prenatal attachment is an abstract concept, representing the affiliative

relationship between a parent and fetus, which is potentially present before pregnancy, is

related to cognitive and emotional abilities to conceptualize another human being, and

develops within an ecological system” (2003). Working on the assumption that MFA exists,

instruments developed from the psychodynamic approach will be employed to examine the

cognitive and emotional abilities of an expectant mother to conceptualize her own mother as

well as her fetus. Additionally, in view of the proposition that emotional factors preexisting

pregnancy are important potential determinants of prenatal attachment (Doan et al., 2003;

Mikulincer et al., 1999), the contribution of personality variables will be examined (Blatt,

Shahar, & Zuroff, 2001; Priel et al., 1999). The “ecological system” in this work will consist

of the situation of hospitalization due to high maternal or fetal risk, defined earlier as an

increased probability of fetal anomaly, compromises of maternal or fetal health, or maternal

or fetal demise. The literature review has been conducted consistent with these factors of

interest.

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CHAPTER TWO

Review of the Literature

Since Cranley’s creation of a measure for her theoretical construct of maternal-fetal

attachment (MFA), there have been approximately 50 published studies incorporating some

measure of antenatal attachment in the research. The psychosocial variables examined have

included social support, interpersonal relationships, self-esteem/self-concept/sense of

mastery/efficacy, anxiety, depression, stress, and coping styles. Demographic characteristics

such as parity, age, level of education, and ethnicity have been incorporated into hypotheses

or analyzed post hoc. Biological variables such as previous substance abuse, maternal health

history, previous perinatal deaths, and maternal/fetal health outcomes have also been

correlated to attachment, and some studies have divided their sample by the presence or

absence of maternal-fetal risk. A few studies have concentrated on women with some level

of this risk, and even fewer have focused exclusively on women with risk severe enough to

require hospitalization. To date, there have been no examinations of the possible

relationships between personality style, object representations, severity of risk, and

attachment within a hospitalized population. However, there are bodies of research that

contribute significantly to our understanding of these factors in other contexts and with other

populations.

25

SEARCH METHODS

Relevant MFA studies published from 1981 (publication date of the Maternal Fetal

Attachment Scale) through 2005 were located through the use of various databases, including

Medline, Psychological Information, and Cumulative Index to Nursing and Allied Health

Literature. An ancestry approach (tracking research cited in studies reviewed) was also

employed to ensure the review of any articles missed in the database search. Dissertations

were excluded, as were articles written in languages other than English. The keywords used

were prenatal attachment, antenatal attachment, MFA, maternal-fetal attachment, internal

working model, object representation, mental representation, prenatal object relations,

personality, and high risk pregnancy. Abstracts of all articles supplied in the database

searches were reviewed to identify studies relevant to this review. Studies that incorporated

measures and discussions central to prenatal attachment, object representation, and

personality characteristics were all considered relevant. While this study is confined to

women who are hospitalized, studies that included non-hospitalized women were included in

light of the paucity of research with the hospitalized population. The studies reviewed are

categorized by their contribution to the understanding of the relationship of attachment to

object representation, personality, and risk.

INTERNAL WORKING MODELS AND OBJECT REPRESENTATION

Background

Bowlby’s premise of internal working models is reminiscent of the concept of object

representation proposed by Melanie Klein, from the very psychoanalytic approach that

26

Bowlby questioned. However, his concept of the “internal working model” has been

attributed to the psychologist and philosopher Kenneth Craik and his 1943 work, The Nature

of Explanation (Bretherton, 1992). Craik proposed that the human mind built “mental

models” of reality that were utilized to anticipate events and produce action. This internal

representational paradigm fit well with Bowlby’s belief that some cognitive mechanism was

at work with the biological system of attachment, for notice his connection in Attachment

and Loss Volume I: Attachment:

“If an individual is to draw up a plan to achieve a set-goal not only must he have some sort of working model of his environment, but he must have also some working knowledge of his own behavioural skills and potentialities… Henceforward the two working models each individual must have are referred to respectively as his environmental model and his organismic model… The environmental and organismic models described here as necessary parts of a sophisticated biological control system are, of course, none other than the ‘internal worlds’ of traditional psychoanalytic theory seen in a new perspective” (p.82).

The “new perspective” in this case had several facets. First, Bowlby held that these models

were based on real experience. Psychopathology resulted because a model “might become

totally out-of-date, or because it is only half revised and therefore remains half out-of-date, or

else because it is full of inconsistencies and confusions” but not because of unconscious

drives that generated fantasies that became internal representations (Bowlby, 1969). Second,

Bowlby pulled from the work of Spitz and Piaget to support his proposal that infants before

the age of nine months were not aware of the human characteristics of the “object;” in fact,

an infant could not even perceive of the “object” as having any permanence. He favored

Spitz’ term, “pre-object relation,” as well as Spitz’ idea that a smiling infant was responding

to a “visual gestalt signal,” not relating to a human. This fit in nicely with Bowlby’s thesis

that the five responses which made up attachment behavior—sucking, clinging, following,

crying, and smiling—were behavior patterns specific to man in much the same way that each 27

species in the animal world was endowed with its own peculiar repertoires of behavior.

Third, Bowlby also differentiated his term “instinctual response” from the usage of the term

“instinct” in psychoanalytic terms. Whereas psychoanalytic instinct referred to a

motivational drive, Bowlby’s term referred to an “observable pattern of behavior” that served

the evolutionary purpose of survival (Bowlby, 1986). Bowlby believed that during

maturation these early behavior patterns would move between various states of latency and

activity, being used in “fresh combinations.” Even the infantile behaviors like crying and

clinging would re-emerge in situations of danger, illness, or helplessness. Stress and

uncertainty could compromise adult-acquired defenses and infantile internal working models

would serve as defaults to guide behavior.

On the other hand, Melanie Klein’s conceptualization of “internal objects” (“object”

referring to a significant person in an emotional relationship) came from the psychoanalytic

view that Bowlby believed needed a “new perspective.” Klein extended Freud’s role of

fantasy as a specific mental process provoked by frustration to that of an elaborate collection

of unconscious images and knowledge that are the core of all mental processes. Klein

theorized that the child’s mental life is filled with fantasy as he establishes a complex set of

internalized object representations based on his experiences with primary caregivers. These

fantasies and anxieties concerning the internal objects become the underlying basis for an

individual’s behavior, emotions, and sense of self. Like Freud, she fueled these fantasies

with hypothesized libidinal drives and oedipal conflicts; unlike Freud, the drives are

essentially psychological forces always directed toward objects. Kleinian internal objects are

largely fabrications of the child’s unconscious drives and wishes inspired by the child’s

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experience with real others (Greenberg & Mitchell, 1983). This drive model was integral to

the discussions of the psychological processes in pregnancy conducted by the earliest

psychoanalysts (Deutch, 1945; Benedek, 1959; Bibring, 1959).

Another contrast between attachment theory and object relations theory is how

research for each of these models was conducted. In the psychoanalytic world, investigations

of object representation were usually based on clinical case studies. Since quantitative

research was not an appropriate venue for exploring abstract conceptualizations of drive

theories, most writings were of clinical experiences with patients, often quite ill individuals.

Attachment theory, on the other hand, essentially came from work and study with normal

children and adults. The influence of ethological and biological research on these theorists

propelled them into empirical based research methods that had far greater generalizability

than the case-study driven work of the psychoanalysts.

Integration of Theory

For decades differences like these between attachment theorists and psychoanalytical

object-relational theorists prevented them from engaging in collaborative dialogue. In recent

years, there has been movement toward an integration of ideas made possible by several

changes. Peter Fonagy outlines these as: 1) A trend in attachment theory to move focus from

infant behavior and external determinants to greater interest in internal representations in

both infant and parent; 2) growing importance for observational and empirical research in the

psychoanalytic community, due to an awareness of the shortage of models that are both

scientifically acceptable and relevant to clinicians; 3) an openness between theoreticians to

integrated approaches and new ideas; and 4) the realization on the part of attachment

29

theorists that without growth through the integration of other approaches the attachment

model would remain stunted in terms of providing value to clinical work, enriching research,

and developing new theory (Fonagy, 2001a). Integrating Bowlby’s internal working model

with object representation is such an example of this new landscape.

Today’s understanding of internal working models is an amalgam of the contributions

of Bowlby, Ainsworth, Bretherton, Mulholland, Crittenden, Main, and Sroufe (Fonagy,

2001a). Fonagy depicts their composite description of the internal working model as an

evolution of four basic components: 1) Expectations based on transactions with and

interactive attributes of the primary caregiver created in the first year, 2) event

representations generated by general and specific memories of attachment-related

experiences, 3) autobiographical memories by which specific events are connected and

contribute to an ongoing personal narrative, and 4) the resulting inferential understanding of

the psychological characteristics of others and self (p. 14). Moving past the strict

interpretations of an internal working model as an imprint of historical relational

interchanges and an object representation as an elaborate concoction of libidinal-driven

fantasy allows a fresh paradigm: Mental representations and internal working models can be

described as reflections of reality-based early experiences with caregivers that are colored by

internal perceptions and transformations (Priel & Besser, 2001). Not ignoring the gap

between attachment and object relational theories, it has been proposed that these two

concepts overlap in a fashion that allows the quality of mothers’ mental representations to

predict the mother-infant attachment (Levine et al., 1991). This reconciliation of approaches

30

has inspired new forays in research with clinical relevance, particularly in the discussion of

MFA.

MFA and Object Representation

Attachment

Bowlby himself believed that the transition of a woman to motherhood mobilized the

same “forces” that had in early infancy and childhood attached her to her own mother (1986).

Some years later, Rubin restated this in her early discussion of the tasks required to fully

attain the maternal role, reporting “Mother was a major prototype and was the most

significant contributor of subject’s set of anticipations in becoming a mother” (Rubin, 1967).

If the participant’s mother was deceased, she was either interjected into the interviews in the

form of memory, or augmented by an aunt, mother-in-law, grandmother, or a person of the

mother’s generation who may have had a maternal relationship with the subject. Rubin

likened this to the “binding-in” task with the fetus, stating that her subjects seemed to also be

“binding-in” again with the mother or mother substitute. In cases where the expectant

mother was separated from her mother by distance, Rubin found that often there was an

actual or “wished-for” trip that seemed almost like a “pilgrimage.”

While not specifically looking at MFA, the Fonagy, Steele, and Steele (1991)

research appears to be the first that empirically explored the association between adult and

infant attachment style in a prospective manner beginning in pregnancy. In this longitudinal

study, the Adult Attachment Interview (AAI) was administered to 100 primagravidas in their

last trimester of pregnancy. At 12 months postpartum, the mothers and infants were assessed

in the Strange Situation exercise. An impressive 75% of mothers categorized as secure had

31

securely attached children; 73% of mothers classified in one of the insecure descriptions had

insecurely attached children. A second finding relevant to the discussion of object

representation in internal working models is that the quality of those relationships could be

measured by the expectant mother’s ability to articulate a complex representation of the

expectant mother’s relationships with her parents. These women were able to:

“fluently convey a global representation (whether favorable or unfavorable) of what her relationship to each parent was like during her childhood…she demonstrates an understanding of her own personal development that includes an awareness of the multiple motives (conscious and perhaps unconscious) that guided her parents’ behavior toward her…there are no significantly distorting mental processes at work (pg. 901).

These robust findings were not totally unexpected; Mary Main, one of the developers

of the AAI, had herself wondered if adult attachment interviews might have something to say

about the mechanism behind the intergenerational cycle of child abuse (Main & Goldwyn,

1984). In a study of 30 normal, non-abusive women whose children had 4 years earlier

participated in an Ainsworth Strange Situation study, Main found that a mother’s experience

of her own mother as rejecting was related to her rejection of her own infant. In addition,

these women also revealed systematic cognitive distortions, such as idealization of the

rejecting parent, difficulty in remembering childhood, and incoherency in discussing their

attachment to their mother. Main found one exception: Women who could coherently

describe their rejection by their mothers, expressing resentment and anger, did not exhibit the

same avoidant behavior toward their own infants. Evidently, the differences in attachment

patterns in these children and women were also related to important cognitive differences, as

illustrated by the degree of cohesion and consistency the adults were able to utilize in their

narratives (Main et al., 1985).

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Integrating Main’s findings, Fonagy’s team hypothesized that internal working

models become activated by certain expectations or events, influencing attachment-related

cognitions and behaviors that may be best thought of as “attachment states” (Fonagy et al.,

1991). These are distinct from the internal working model which, along with personality

traits, predisposes individuals to feelings and behaviors. Their recommendation was that

models of attachment could be informed by the examination of representational processes

that influence attachment-related emotions, thoughts, and behaviors.

The AAI and the Strange Situation have been paired in research repeatedly since the

Main and Fonagy studies, with findings suggesting that attachment classifications are stable

even across three generations (Zeanah et al., 1993; Benoit & Parker, 1994). Meanwhile,

interest in MFA began increasing in the field of study devoted to child and adolescent mental

health. A pair of child psychiatrists introduced the Working Model of the Child Interview

(WMCI), a measure designed to evoke mothers’ internal representations of their infants.

Modeled after the AAI, this one-hour structured interview categorically scored a caregiver’s

perceptions and subjective experience of their child. Qualitative, content, and affective

features of the narrative result in the assignment of one of three classifications: Balanced,

disengaged, or distorted. “Balanced” responses convey relatively rich details about the

infant, including both positive and negative characteristics of the infant or the mother-infant

relationship. “Disengaged” narratives are cool, distant, or indifferent descriptions that

implied the infant’s experience was either unrecognized or disregarded; descriptions are

unelaborated, giving the sense that the caregiver does not truly know the child. “Distorted”

representations are internally inconsistent, confusing, unrealistic, and divulge a lack of

33

insight concerning the impact of parenting upon the infant. In two independent

investigations with samples of mothers and their 12-month-old infants, they found that the

mothers’ WMCI classifications were significantly correlated to their infants’ attachment

classifications according to the Strange Situation. Narratives classified as “balanced” were

associated with secure infants, “disengaged” with insecure-avoidant babies, and “distorted”

with insecure-resistant children. Benoit et al. replicated the study with 96 expectant mothers

in the third trimester of pregnancy (Benoit, Parker, & Zeanah, 1997). When the WMCI was

repeated one year later concurrent with the Strange Situation, not only were WMCI

classifications significantly stable over time for the mothers, but the pregnancy WMCI

results predicted infant Strange Situation classifications in 74% of the cases. Concordance

between 12-month WMCI and Strange Situation classification was 73%. The authors felt

that this association could have major implications for early identification of high-risk

parent-infant relationships.

Only two other research teams to date have published empirical studies of the

relationship between MFA and object representations. Levine et al., working with a sample

of 42 pregnant adolescents, hypothesized that object representation during pregnancy could

be a predictor of infant attachment style (1991). The AAI was administered before childbirth

and the Strange Situation was conducted when the 42 infants were 15-months-old. The

quality of object representation was measured by the application of the Krohn Object

Representation Scale for Dreams to the responses of the AAI. The Krohn measure is an 8-

point scale that assesses hierarchical levels of an individual’s maturity of object-

representation and capacity for interpersonal relatedness (Krohn & Mayman, 1974).

34

Originally developed for use with dream analysis, it has been used in a similar way with the

responses of a Rorschach administration; however, there is no information as to its reliability

and validity in the application of it to the AAI. While the method has been questioned (Priel

et al., 2001), this research team did find mothers’ attachment style and object representations

highly correlated, and also found that both were significantly correlated with infant’s

attachment style as categorized at 15 months of age. However, the extent to which these

findings are generalizable is questionable in light of the fifteen-year mean age of this

population. Even considering individual variation in the development of mental

representations, this process is usually viewed as unfolding gradually through maturation to

adulthood and subject to disruption by developmental demands that are age-inappropriate

(Blatt, 1974).

Overlapping Models

What exactly has been measured in this body of research? Since the AAI has formed

the basis for these analyses, is the discussion so far one of internal working models or of

object representation? While the two concepts are related, they are not identical, and as such,

may not have the same contribution to MFA. Internal working models might be described as

templates of relationships (Main et al., 1985). In contrast, object representations reflect the

internal transformations of early relationship patterns, thereby guiding the use of and

affecting the organization of those templates (Fonagy et al., 1991). The AAI was designed

to elucidate early patterns of reality-based attachment relationships and the participant is

asked to reflect on what those mean to him or her currently. The WCMI was constructed on

the same theoretical base; their correspondence is perhaps not surprising. The findings of

35

these analyses may certainly be revealing what sort of template an individual is describing,

but an understanding of what links internal working models with antenatal or maternal-infant

attachment continues to be elusive for these researchers. Some theorists, following Main’s

concept of maternal sensitivity, have assumed that maternal responsivity/sensitivity mediates

maternal attachment and infant security (van Ijzendoorn, 1995). This assumption has not

been proven, however, and other attachment theorists point to analyses of discordant mother-

infant dyads and counter that sensitivity is more accurately thought of as a moderator that can

block an attachment state of mind, as when a mother with an insecure attachment style is

found to have a secure infant (Atkinson et al., 2005). Therefore, if the interest is in what

activates a template or internal working model perhaps another form of measurement is

needed.

With this in mind, Priel and Besser of Ben-Gurion University in Israel formulated and

tested their hypothesis that a pregnant woman’s antenatal attachment and internal working

models would be mediated by the expectant mother’s internal representation of her own

mother on a sample of 120 first-time mothers in the third trimester of a low-risk pregnancy

(2001). Their strategy was to utilize operationalizations of internal working models and

object representations that corresponded to Bartholomew & Horowitz’ conceptualization of

adult attachment and Blatt and colleagues’ means of identifying object representations,

instead of the traditional Ainsworth/Main constructs of adult attachment and internal working

models (Bartholomew et al., 1991; Blatt, Chevron, Quinlan, Schaffer, & Wein, 1992a). The

Bartholomew and Horowitz conceptual development was an outgrowth of Hazan and

Shaver’s application of George and Main’s attachment categories of the AAI to the romantic

36

attachment that develops between adults (Hazan et al., 1987; George et al., 1985). As a

result of noticing a difference in the motivations behind avoidance when exhibited by

dismissive behavior (George and Main’s category) as opposed to fearful behavior (Hazan and

Shaver’s category), Bartholomew & Horowitz hypothesized a classification of adult

attachment that is defined by the positivity of the internal working models of self and other.

Four dimensions of positivity/negativity of self/other could explain four models of

attachment: secure (positive self/positive other), preoccupied (negative self/positive other),

dismissing (positive self/negative other), and fearful (negative self/negative other). The

measure that resulted from this exploration, the Relationship Questionnaire (RQ), contained

four paragraphs, each describing a particular attachment pattern. Participants were first

asked to identify which is most descriptive of self, and secondly to indicate on a 5-point scale

the extent to which each of the four paragraphs are like self. Object representation in the

Priel and Besser study was evaluated using the Object Relations Inventory (ORI), an open-

ended description of mother that is analyzed across six dimensions: Benevolence,

punitiveness, ambition, ambivalence, complexity, and conceptual level (Blatt et al., 1992a).

These measures were then compared with MFA as measured by the Condon measure of

MFA quality and intensity (MFAS; Condon, 1993). Several findings of interest emerged in

this work: (1) Participants classified as “secure” on the adult attachment measure had

maternal representations that were more benevolent and ambitious and less punitive and

ambivalent than the representations of the three “insecure” groups (preoccupied, fearful, and

dismissing). The secure group’s representations were also significantly more complex and

displayed a higher conceptual level, a skill that statistically declined from the secure group to

37

the insecure-fearful and from the fearful to the insecure-preoccupied. (Conceptual

development on the ORI is established by assessing the range of ways in which the “other” is

experienced as described in the narrative. Five conceptual levels, Sensorimotor

Preoperational, Concrete-Perceptual, External Iconic, Internal Iconic, and Conceptual

Development are used as anchor points in the scoring.) The insecure-dismissive group

generated the least conceptually developed maternal representations (all differences

significant at p < .001). Significant effects were also found between the four attachment

groups and the quality and intensity of MFA, with preoccupied participants scoring

significantly lower on both dimensions. They concluded this work supported the hypothesis

that internal working models and object representation coexist, particularly since maternal

representation was found to “fully mediate the association between internal working models

and antenatal ties to their babies.”

Using a different measurement for maternal parental representations, Priel and Besser

in another study investigated adult attachment styles, early relationships, antenatal

attachment, and perceptions of infant temperament in first-time mothers (2000). In a

longitudinal study of 115 mothers of healthy babies that began in pregnancy, the team found

that mothers who experienced their own mothers as supportive and non-intrusive were not

only secure, but reported higher MFA and perceived their 4-month-old infants as having an

“easier” temperament than those women with less positive maternal experiences. In this

study, the adult attachment category was derived from Bartholomew and Horowitz’ system

and antenatal attachment was measured with Condon’s MAAS. Maternal relationships were

analyzed using the Parental Bonding Instrument, a 25-item self-report measure of

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participants’ memories of parental behaviors and attitudes (Parker, Tulping, & Brown, 1979).

Once more, they seemed to identify an association between mothers’ representations of their

own caregivers, mothers’ romantic attachment style, and antenatal attachment.

Priel and Besser’s travel to their conclusions may have taken a different avenue than

the Fonagy group, but they are nevertheless concordant. Fonagy et al. recognized that

attachment states might be activated by an overall organization of mental structures, not

purely by quality of early attachment experience (1991). Perhaps Priel and Besser have

introduced a rationale for the 25% discordant mother-infant dyads in the Fonagy study.

Missing from the knowledge at this point is what a mother’s object representation of

her fetus would be. Recall that earlier research described expectant mothers as able to

describe their fetus in human terms and as separate from self in an increasingly coherent way

as pregnancy progressed (Lumley, 1982; Stainton, 1990). The WCMI is a valuable tool for

insight into parental attitudes of their child, but perhaps more descriptive of the “baby

template” than of a developing mental representation of their fetus. It is the goal of this

research to investigate object representation in the fashion of Priel and Besser. In addition to

examining mental representations an expectant woman expresses of her mother, an ORI

analysis of the expectant mother’s conceptualization of her unborn child will also be

introduced.

THE CONTRIBUTION OF PERSONALITY

Although the earliest explorations into the experience of pregnancy promoted it as a

psychological process (Benedek, 1958; Bibring et al., 1961; Rubin, 1975; Rubin, 1967;

39

Leifer, 1977), and pregnancy is undoubtedly one of the most important periods of a woman’s

adult life, the contribution of personality to MFA has not been widely explored. It has been

suggested that the associations among personality, stress, and the development of close

relationships should be considered in future discussions of attachment (Mikulincer et al.,

1999). While infant temperament has been explored (Lorensen, Wilson, & White, 2004),

other than examining the relationship of self-esteem with MFA (Curry, 1987; Cranley, 1981;

Gaffney, 1989; Kemp & Page, 1987; Koniak-Griffin, 1988), relatively few studies have

incorporated personality measures in the analyses, and one research team has produced most

of the literature available (Pollock & Percy, 1999; Besser & Priel, 2003a; Besser & Priel,

2003b; Reading et al., 1984; Priel et al., 1999; Priel & Besser, 2000a). Two of these studies

do not contribute much value to this discussion because of the limited information supplied

and the measures used. When Pollock and Percy investigated hypotheses regarding variables

that might be related to self-reported risk of harming one’s fetus in their study of pregnant

women referred by Social Services for psychological evaluation (1999), they employed the

Millon Clinical Multiaxial Inventory-2 (MCMI-2). This self-report measure of personality

was designed to examine dimensions of personality disorder, which facilitated their

investigation of the relationship of borderline personality dimensions and adult attachment

(Millon, 1987). Not only are the results questionable in terms of generalizability to a non-

forensic population, the MCMI-2 was developed to measure psychopathology, not

dimensions of normal personality. Reading et al. reported administering the Eysenk

personality measure but do not report findings (1984).

40

Attachment and Personality in Adult Research

Attachment has been connected to personality style in normal adult populations

(Zuroff & Fitzpatrick, 1995; Morrison, Urquiza, & Goodlin-Jones, 1998), and extensively

explored in relation to psychopathology (Brisch, 2002; Fonagy, 2001b; Blatt, Auerbach, &

Levy, 1997). Quality of attachment has also been associated with perinatal depression

(Mercer et al., 1988; Condon et al., 1997), and individuals with certain personality

characteristics have been observed to be associated with or vulnerable to perinatal depression

(Besser et al., 2003a; Besser et al., 2003b; Steinberg & Bellavance, 1999; Besser et al.,

2003a; Priel et al., 1999; Priel et al., 2000a).

Undoubtedly, cavalierly associating attachment with general personality factors or

associating it with personality dimensions to the exclusion of other important components of

relationship functioning would be counterproductive (Griffin & Bartholomew, 1994).

However, the growing integration of internal working models and object representation and

their association to attachment theory, developmental psychology, social psychology, and

cognitive science has had a major impact on personality assessment (Blatt, Auerbach, &

Lindgren, 1997). Recognition of the centrality of these mental templates and structures to

personality organization and the difficulty of direct measurement has awakened new interest

in the use of projective devices, such as the Rorshach, the Thematic Apperception Test, and

the Krohn Object Representation Scale for Dreams, particularly in the search for new ways

of understanding intractable psychopathology.

Summarizing personality research or even developing any singular approach to

personality is not possible in this discussion, but one particular understanding blends with the

41

experience of pregnancy in an almost seamless manner. Theorists have stated that the

evolution of the capacity for mutuality, or for reciprocal, satisfying, intimate relationships

with others, accompanied by a positive, realistic, and differentiated sense of self, is central to

the human formation of individual personality (Feldman & Blatt, 1996). This interactive,

reciprocal nature (or tension) of the dynamic processes of individuation and relatedness has

often been conceptualized. These have been referred to as: Surrender and autonomy

(Angyal, 1941), moving toward, against, or away from others (Horney, 1945), connectedness

(ocnophilic) and self-sufficiency (philobatic) tendencies (Balint, 1959), communion and

agency (Bakan, 1966), intimacy and autonomy (Shor & Sanville, 1978), sociotropy and

autonomy (Beck, 1983; Beck, Epstein, Harrison, & Emery, 1983) and introjective (self-

critical) and anaclitic (dependent) (Blatt et al., 2001). Correspondingly, the transition to

parenthood for both parents but more specifically the mother, has been painted by many as a

unique, developmental period in which issues of individuation or self-definition, and

mutuality or relatedness are paramount (Diamond, Blatt, Stayner, & Kaslow, 1995; Doan et

al., 2003; Leifer, 1977; Rubin, 1967; White et al., 1999). Therefore, looking at dimensions

of personality that explicate the transition of motherhood in relation to individuation or

mutuality seems most relevant to the relationship between personality and MFA.

Dependency and Self-Criticism

Based upon a history of work with depressed individuals, Blatt and colleagues

proposed a theoretical model of personality development that took into consideration the

state of development of an individual’s concepts of self and other (Blatt et al., 1997; Blatt et

al., 2001; Blatt, D'Affliti, & Quinlan, 1976). Personality in this model develops along two

42

basic trajectories: 1) a line of relatedness to others that incorporates the capacity to form

mature, mutually satisfying relationships, and 2) a line of self-definition that involves

developing an integrated, realistic, positive and differentiated identity. These two

dimensions, termed “anaclitic” and “introjective” respectively, develop throughout life, each

dependent upon the other for growth. In psychologically healthy individuals, these two

dimensions are balanced, interactive, and mutually facilitating; an overemphasis of one

and/or the defensive avoidance of the other results in various degrees of psychological

discomfort or disorder. An exaggerated need for and dependence upon others can result in

psychopathologies such as anaclitic (empty or loss-based) depression, dependent personality

disorder, and borderline personality disorder. In contrast, an overemphasis on autonomy and

self-worth can contribute to disorders such as obsessive-compulsive personality disorder,

paranoia, narcissism, and introjective (guilt or failure-based) depression. This two-

dimensional model has been particularly useful in diagnosing and treating depression (Blatt,

1974; Blatt et al., 1976; Blatt & Zuroff, 1992b) and is interestingly similar to Bowlby’s

descriptions of depressed individuals who were either anxiously attached or compulsively

self-reliant (Bowlby, 1980).

Based upon a review of clinical literature, Blatt, D’Afflitti, and Quinlan constructed a

measure containing 66 statements that were not direct symptomatic expressions of depression

but reflected experiences frequently reported by depressed individuals (1976). The items in

the Depressive Experiences Questionnaire (DEQ) encompassed issues such as negative or

distorted sense of self or others, dependency, helplessness, egocentricity, fear of loss,

ambivalence, self-blame, guilt, loss of autonomy, and disruptions in family relationships.

43

Participants rated these items on a 7-point scale indicating agreement or disagreement with

the experience. Statistical analyses of the measure revealed three factors, dependency, self-

criticism, and efficacy (sense of confidence about one’s resources and capacities). A

considerable body of research in the last thirty years has demonstrated its reliability and

validity in a number of populations, including perinatal women (Besser et al., 2003a; Besser

et al., 2003b; Blatt et al., 1976; Blatt, 2004; Blatt, Zohar, Quinlan, & Zuroff, 1995; Blatt,

Schaffer, Bers, & Quinlan, 1992; Blatt et al., 1992a; Bacchiochi, Bagby, Cristi, & Watson,

2003; Bagby, Parker, Joffe, & Buis, 1994; Zuroff, Quinlan, & Blatt, 1990; Priel et al., 1999;

Priel et al., 2000a).

With the aid of the DEQ, research has found parallels between adult attachment styles

(secure, anxious, dismissive, fearful) and Blatt’s dimensions of personality (Zuroff et al.,

1995). Dependent (anaclitic) individuals suffer deep longings to be loved and protected, but

lack confidence that those needs will be met, fearing abandonment in their interpersonal

relationships (Blatt et al., 1992b). Self-critical (introjective) individuals are preoccupied

with constant self-scrutiny, fear being disapproved and criticized, and expect to lose the

approval and acceptance of significant others. When applied to attachment theory, Zuroff

and Fitzpatrick found that both anaclitic and introjective individuals exhibited insecure

attachment styles (1994). Dependent individuals were preoccupied with losing emotional

support from others, and introjective individuals structured relationships to remain at a

distance, perhaps protecting themselves from being hurt but becoming vulnerable to

depression as a result of dissatisfying relationships that lacked intimacy. Imbalances in

these personality styles have also been associated with various problems in social-personal

44

adjustment, including early parent-child relationships (Koestner, Zuroff, & Powers, 1991;

McCranie & Bass, 1984).

Relevant to this topic are three studies focused upon samples of pregnant women

(Besser et al., 2003b; Priel et al., 1999; Priel et al., 2000a). A prospective study of 73

primagravidas in the third trimester of pregnancy tested the hypothesis that dependency and

self-criticism could be vulnerability factors to postpartum depressive symptoms. In addition

to finding that self-criticism measured in pregnancy was significantly predictive of

postpartum depressive symptomatology at eight weeks postpartum, results also indicated that

those introjective participants who were strongly attached to the fetus during pregnancy (as

measured by the Condon instrument) had a lower risk for depression. Dependency was not

associated with depressive symptoms in this study. Priel and Besser suggested that, based on

these findings, implementation of more open and ideographic approaches to the measurement

of personality might allow a more sophisticated evaluation of antenatal attachment. This

might also allow a way to understand the confusion concerning the insecurely attached

mothers with secure infants from the earlier cited findings (Fonagy et al., 1991; Main et al.,

1984).

Another study with a sample of 120 primagravidas explored potential relationships

between personality tendencies, frequency of depressive symptoms, and perceptions of social

support (Priel et al., 2000a). Results revealed depressive symptoms in both highly anaclitic

and highly introjective women seemed to be mediated by a distinct attitude toward and style

of negotiating social support. Self-criticism was found to reduce the perception of available

support while dependency seemed to increase this perception. The conclusion was that

45

personality tendencies do have an effect on perceptions of social support and, indirectly, an

influence on depressive symptoms. This same team then underwent a third look at the

impact of anaclitic and introjective personality tendencies in relation to coping styles in

pregnant women (Besser et al., 2003b). With a sample of 146 women in their first

pregnancies, coping style also emerged as a moderator to trait vulnerability to depression.

The body of research contributed by Priel and Besser encourages further evaluation of

plausible differences between MFA processes among dependent and self-critical mothers.

Development of transactional models would allow focus to shift from simplistic direct

relationships to mutual effects of mental representation, personality variables, and the

demands of the pregnancy experience upon MFA. The variety of measures available today

also enables research teams to quantitatively measure abstract constructs such as object

representation.

THE IMPACT OF RISK

Over a million pregnant women a year are identified as being at high-risk for

maternal or fetal complications, approximately 700,000 of which are treated with bed rest

(Lumley, 2003). When the threat to maternal or fetal health is emergent, hospitalization is

required for intensive monitoring, with the aim of prolonging the pregnancy until the balance

of risk for maternal and fetal safety weighs the uterine environment unsafe to continue. Two

types of high-risk pregnant women have been described: Those with chronic illnesses that

predispose them to risk during pregnancy, and those who are faced with an unanticipated

complication that arises in what has been a normal pregnancy (Heaman, 1998). Maternal

46

risks include the hypertension spectrum (chronic hypertension/preeclampsia/eclampsia),

gestational diabetes (or pre-existing diabetes), severe anemia, and cardio-pulmonary disease

(Hobel, Hyvarinen, Okada, & Oh, 1973). Separate fetal risks include fetal anomaly,

premature rupture of membranes, placenta previa, placental abruption, and premature birth.

Preterm birth, defined by the World Health Organization as any birth occurring

between 20 and 37 weeks of gestation, is the major clinical problem most associated with

fetal demise and childhood disability (Lumley, 2003). Although only 6-10% births are

considered preterm, those births account for more than 60% of all perinatal deaths and nearly

50% of long-term neurological disability (Logghe & Walker, 2004; Wood, Marlow,

Costeloe, Gibson, & Wilkinson, 2000). While advances in neonatal care have increased the

survival rate of premature births, there are marked differences in the probability of survival

according to gestational age, with births from 20 to 27 weeks at the most severe risk for

demise or disability (Lumley, 2003). Rates for neonatal survival before 24 weeks of

gestation are extremely low; at 34 weeks, the survival rate is similar to that of full-term

gestation. Risk factors for preterm birth include previous preterm births, multiple births,

maternal age greater than 35 or less than 15, maternal weight greater than 200 or less than

100 pounds, history of abortion (spontaneous and/or elected), and poor maternal health

practices, such as smoking and substance abuse.

Obstetric Risk and Perinatal Mental Health

What past research has strongly suggested is that high-risk pregnancy alone, without

required hospitalization, is associated with increased rates of depression and anxiety (Kurki,

Hiilesmaa, Raitasalo, Mattila, & Ylikorkala, 2000). Studies focusing on hospitalized women

47

have identified higher levels of anxiety and depression, lower self-esteem, less positive

expectations for their experience of childbirth, and less optimal family functioning than

found in non-hospitalized women (Heaman, 1992; Maloni, Park, Anthony, & Musil, 2005;

Maloni & Park, 2005; Maloni, Kane, Suen, & Wang, 2002; Maloni & Kasper, 1991; Mercer

& Ferketich, 1988; Heaman, Beaton, Gupton, & Sloan, 1992; White & Ritchie, 1984;

Leichtentritt, Blumenthal, Elyassi, & Rotmensch, 2005; Mercer et al., 1994), and negative

affect during pregnancy has been associated with adverse obstetric and neonatal outcomes

(Kurki et al., 2000). Maloni et al. found that dysphoria (a composite of anxiety, depression,

and hostility) was highest upon hospital admission and was significantly greater for those

with the highest Hobel Risk Assessment scores (2002). Another finding was that gestational

age at birth was significantly correlated with postpartum dysphoria. Priel and Besser also

found increased levels of postpartum depression in a selected group of high-risk pregnant

women whose pregnancies ended well (Besser, Priel, & Wiznitzer, 2002), lending to the

hypothesis that these women may have postponed maternal bonding, which is considered a

protective factor against the vulnerability to depression (Priel et al., 1999). Gupton et al.

points out the quandary that exists with the multiple findings available: Stress and anxiety are

associated with increased risk of preterm birth and low birth weight, psychosocial factors

such as depression, anxiety, and low self-esteem have been shown to be associated with

higher incidences of poor health practices, and women experiencing a high-risk pregnancy

have higher levels of stress and anxiety, but how these factors are all related is basically

unknown (Gupton, Heaman, & Cheung, 2001). The preponderance of evidence suggests that

women with complicated pregnancies suffer from symptoms of anxiety and depression as

48

they experience threats to self and fetus and feel a loss of control. Little is known about how

long these symptoms last, whether they continue into the postpartum period, and how or if

they affect the attachment process.

Issues Specific to High-Risk Pregnancies

The first discussion of the psychological implications in high-risk pregnancy was

published in 1982 by Joy Penticuff, who provided the definition of high-risk commonly used

today. Using the theory of development during pregnancy proposed by Rubin and others, she

outlined five important issues high-risk couples face in their adaptation to pregnancy and

parenthood. Penticuff’s first point is that in uncomplicated pregnancy, ambivalence

regarding the changing roles and addition of a child to the family is usually resolved by the

end of the first trimester. However, this resolution of ambivalence can be compromised

when negative physical signs indicate danger to the fetus. When parents are informed that

there is possibility that the baby may not survive or may be born with disability, the

ambivalence toward the pregnancy is intensified. The contrasting feelings change—instead

of resolving the transitional issues of becoming a mother, the feelings become a mixture of

intense desire for a healthy baby and the fear that the baby will not live or will be damaged.

Secondly, with the possibility of a fetus that may never live, or may live but be

disabled, parents may find it hard to allow the natural growth of attachment to the baby. Fear

of disappointment and loss may thwart the normal trajectory of increasing MFA. For

hospitalized women, this danger is salient with the omnipresent fetal monitor, daily physician

visits, physical symptoms, periodic hospital tests, and separation from home and family.

49

Signs of an uncomplicated pregnancy (e.g. weight gain, appearance of the pregnancy

to others, unrestricted activity level) contribute to the sense of adequacy an expectant mother

develops through the gestational period. In high-risk pregnancy, there may be negative signs

instead, such as poor weight gain, bleeding, contractions, and prescribed bed rest that

threaten her sense that she will be able to achieve successful pregnancy and childbirth.

Feelings of threat, isolation, and a loss of control may thwart the development of maternal

adequacy and spill over into a continuing sense of inadequacy when the baby is born.

Penticuff believed women with high-risk were especially vulnerable to feelings of self-blame

and failure.

The fourth issue targeted the impairment of traditional nesting behaviors. In normal

pregnancy, the last trimester is typically spent acquiring the necessities for infant care,

selecting and preparing the layette, and decorating the nursery. Friends and family plan baby

showers, and the atmosphere is one of excitement and joy. When complications occur, all

these activities are suddenly curtailed (or may never take place), the prevailing atmosphere

becomes one of anxiety, and friends and family members are not sure what to do or say.

Finally, the very expectations of labor and delivery change. While there is always

some element of anxiety in approaching the birth experience, certain positive expectations

are in place. Couples participate in birthing classes, tour labor and delivery facilities,

imagine what seeing their baby for the first time will be like, and mothers consider breast-

feeding. Complications change all these expectations—labor and delivery are uncertain.

There may be no time for classes and tours, no choice to breastfeed an extremely premature

50

neonate, and couples must prepare themselves for the possibility of an emergency delivery

and the risk their child will not survive.

In summary, high-risk pregnancy sends an expectant mother into a state of “limbo,” a

place of uncertainty accompanied by an overwhelming sense of vulnerability, with a

realization of the loss of control and the need to surrender autonomy. “Others” take on new

significance, from the medical professionals who bring the good and the bad news, to the

husbands, friends, and families who bring food and stories of the outside world; dependency

is somewhat forced upon a high-risk mother. Since Bowlby held that the attachment system

was found to be most strongly activated under conditions of distress such as fatigue, illness,

or fear, this environment seems ideal for an investigation of attachment (Bowlby, 1973).

Previous Research with Hospitalized Populations

Only three studies of MFA have been conducted using samples that included

hospitalized women. The earliest publication reported findings on a prospective, descriptive,

correlational study of 75 women hospitalized with complications in their third trimester of

pregnancy (Curry, 1987). Curry wondered if social support and self-concept could be

intervening variables between maternal behavior and maternal history of stress. She also

wanted to take the opportunity to summarize the feelings these hospitalized women had

regarding their pregnancies and babies. Although she was unable to support her hypothesis

concerning intervening variables, there were several findings pertinent to this discussion.

There was a significant positive correlation between Cranley’s MFAS scale and the self-

concept measure Curry employed, indicating that women with high measures of self-concept

also reported high MFA. Curry hypothesized this supported a profile of women with poor

51

self-concept, perhaps as a result of inadequate mothering, who then were vulnerable to

negative effects from a high-risk pregnancy. This hypothesis was later supported by Priel

and Besser’s study of the association between introjective women and postpartum depression

in uncomplicated pregnancy (1999). Secondly, women who reported better relationships

with their mothers also scored higher in the MFAS, supporting both attachment and object

relations theories of the developments during pregnancy. However, without specific

measures of mental representation that conclusion could not be made. Curry believed that

future research using grounded theory and qualitative methods would continue to broaden the

understanding of women’s feelings in high-risk pregnancy, enable identification of women

vulnerable to negative psychological effects from the risk, and develop interventions aimed

at improving self-concept in these women.

The other two research teams investigating MFA in hospitalized women were led by

Mercer, an early spokeswoman for nurses concerned with expectant mothers at risk (Mercer,

1977; Mercer, 1983). The first study of expectant couples included 153 high-risk

hospitalized women (75 mates) and 218 low-risk women (147 mates) in the third trimester of

pregnancy (Mercer et al., 1988). Mercer expected to find no effects upon maternal or

paternal attachment (measured by Cranley’s MFAS and PFAS) of the variables social

support, self-esteem, sense of mastery, general health, marital relationship, family

functioning, life experiences, anxiety, depression, early relationships with parental figures, or

readiness for pregnancy. All measures used were self-report questionnaires, and the ability

of some to relatively capture the variable of interest is unclear. For example, in evaluating

early relationships with parental figures, Mercer et al. used a single question with a 5-point

52

Likert-type scale. It is doubtful that this would have the same predictive power of a more

comprehensive tool. While their statistical analyses did not find significance, there were

interesting trends that are informative. 25% of high-risk women conveyed worry, anxiety,

and concern compared to 8% of low-risk subjects; 11% of high-risk women reported loving

or talking to their fetus compared with 18% of low-risk subjects; only 23% of high-risk

women expressed being curious about and anticipating birth, in contrast to 48% of the low-

risk subject. The study also suffered from a 41% refusal rate of the high-risk women at the

facility from which the sample was drawn, among which 70% were not Caucasian. In

addition, the authors themselves considered that the measures utilized may not be accurately

capturing the parameters of the MFA construct.

Six years later, Mercer led another team comparing 121 high-risk women and 182

low-risk women at 5 time points: Antenatal (hospitalization for the high-risk group),

postpartal hospitalization, 1, 4, and 8 months postpartum. The hypotheses this time were that

high-risk women would report lower maternal role competence than low-risk women, and

that there would be a significant relationship between maternal competence and maternal

attachment from postpartal to 8 months postpartum. Hypothesis one was rejected, as no

significant differences were found in the maternal role competence of either group over time.

However, self-esteem and mastery were consistent predictors of maternal competence for

both groups. Fetal attachment was a consistent predictor of competence only in the high-risk

group, suggesting to the authors that perhaps these women had been sensitized to the value

they placed on safely delivering their babies. Depression also explained more variance in the

reported maternal competence of the high-risk group at 1 month postpartum, and continued

53

to have an effect on scores through the last time point. State anxiety was a major predictor to

maternal competence for both groups, but only at the postpartal time point. Although fewer

measures were used with this study, the ones used were identical to those in the previous

study, making it difficult to determine if the findings were consistent because they are

meaningful or because the measures were the same as those previously used.

CONCLUSION OF REVIEW

A study of the MFA construct in a sample of hospitalized women would add value to

the body of research that is available and perhaps begin addressing previously unanswered

questions. Viewing the high-risk population as an avenue to better understand the process of

attachment has merit from both attachment and object relational theoretical approaches, for

this group of individuals is in the exact climate Bowlby believed activated attachment

emotions, cognitions, and behaviors. Gaining an understanding of how mental

representations may motivate those reactions could refine our understanding of MFA, help

identify those with compromised attachment systems, and inspire interventions aimed at

causal mechanisms instead of symptoms. And an understanding of personality tendencies

may help tie the mechanisms of attachment and object representation together in a manner

that exposes or explains associations as well as individual differences.

RATIONALE FOR THIS RESEARCH

Findings in the literature have been inconsistent regarding the implications of risk on

maternal-fetal attachment (MFA), and there is a paucity of research investigating the impact

of hospitalization on the development of this attachment. Reviews of extant published

54

studies have consistently pointed out the necessity for additional correlational research to be

conducted with this population for two specific scientific reasons: Existing MFA measures

have not been validated outside the population of low-risk pregnant women, and there is a

need for increased knowledge regarding the construct of prenatal attachment and the

contributions of object representation and personality. This study would provide an

investigation of both.

Indirect benefit of this work could be realized as well. If women at risk for weak

attachment can be identified before childbirth, then future longitudinal study of interventions

would be justifiable and important. Successful development of interventions would require a

more refined understanding of MFA across populations (Cranley, 1992). Since strong MFA

has been linked with positive health practices during pregnancy, enhancing attachment has

the potential of reducing perinatal risk and improving the health of perinatal women and their

infants. Although findings are inconsistent, there is some suggestion that strong MFA is a

protective factor against postpartum depression; prenatal interventions with women at risk

for this tragic illness are important for mothers and babies. Current work in Germany is

suggesting that prenatal interventions do improve the sensitivity of mothers at risk for poor

caregiving (Brisch, 2002) and past research in the U.S. has proposed simple interventions

nurses can employ with women to enhance attachment (Carter-Jessop, 1981). Sound, theory-

driven studies are a necessary foundation for any of this work.

55

AIMS OF THE STUDY

The primary goals of this dissertation research are: 1) To investigate to what extent

maternal and fetal representations influence an expectant mother’s ability to form attachment

with her fetus in the uncertainty of maternal and/or fetal risk factors significant enough to

require hospitalization, and 2) to explore the association between personality, object

representation, and MFA.

Secondarily, interrelationships between object representation, personality, type of

risk, severity of risk, gestational age of fetus at time of onset of complications, and

depression will be analyzed.

HYPOTHESES

Primary Hypotheses

Hypothesis One

It is hypothesized that, in a hospitalized sample of high-risk pregnant women, those

participants expressing complex, highly integrated conceptual levels of representation of

their own mothers (as evaluated by the Conceptual Level scale of the Object Relations

Inventory) will report both a higher quality and greater intensity of attachment (as measured

by the Maternal Antenatal Attachment Scale) to their unborn babies than those whose

maternal representations are less highly developed.

56

Hypothesis Two

It is also expected that those individuals who are able to articulate more complex

representations of their mothers will also be able to do so of their babies (as evaluated by the

Conceptual Level scale of the Object Relations Inventory).

Hypothesis Three

Dependency (as identified on the Depressive Experiences Questionnaire) is expected

to be more highly associated with anxious/ambivalent prenatal attachment (as categorized

from the Maternal Antenatal Attachment Scale) while self-criticism (as identified on the

Depressive Experiences Questionnaire) is expected to be more highly associated with a

positive quality of attachment but low preoccupation (as categorized from the Maternal

Antenatal Attachment Scale).

Hypothesis Four

In addition, it is predicted that women with a self-critical personality style will

convey object representations of a higher conceptual level (as evaluated by the Object

Relations Inventory) and report a higher quality of attachment than women with a dependent

style.

Secondary Hypotheses

Hypothesis Five

Since some risks are to mother and others to fetus within high risk pregnancy, the

relationship between maternal representation/fetal representation (as evaluated by the Object

Relations Inventory) and attachment (as measured by the Maternal Antenatal Attachment

Scale) is suspected to be influenced by the type of risk described to the participant by her

57

physician. Risk in this study will be categorized as primarily maternal or primarily fetal.

Severity of risk will also be taken into account, stratifying risk as low, medium, and high,

based on the physician’s diagnosis and the Hobel Risk Assessment score. Specifically, it is

expected that fetal risk will be associated with a higher global score of the Maternal

Antenatal Attachment Scale than maternal risk.

Hypothesis Six

It is also expected that the intensity subscale scores of this measure will be higher in

patients with identified fetal risk.

Hypothesis Seven

It is also expected that gestational age of the fetus at time of onset of complications

will be positively correlated with the global attachment score.

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CHAPTER THREE

METHODOLOGY

PARTICIPANTS

Participants were a sample of women with maternal and/or fetal risk severe enough to

require admission to the antenatal unit of Baylor University Medical Center. The antepartum

unit often receives patients who are admitted for less than 24 hours, making complete data

collection on all new admits unfeasible. In order to minimize missing data, participation in

the study was limited to women admitted to the antenatal unit of Baylor University Medical

Center with the expectation of a hospitalization longer than 72 hours. Women who were

actively psychotic, suicidal, or homicidal were excluded from the research, as were any with

cognitive impairment.

METHODS AND PROCEDURES

The study coordinator reviewed the antenatal unit’s daily log of admissions and

discharges from the floor. Information from the charge nurse regarding the proposed length

of stay determined if new admissions were solicited for the study. Patients expected to

remain in the unit for at least 72 hours were approached in their hospital rooms and the

project was introduced as a study of women’s experiences during hospitalization for

complications of pregnancy. After obtaining consent (Appendix A), a member of the

research team obtained demographic information, explained the self-report measures, and left

59

the packet with the patient for completion, arranging to return for it at a designated time. The

investigator also reviewed medical records to obtain relevant medical information including

gestational age and factors of mother/baby risk. To ensure confidentiality, each mother was

assigned a participant number and all study materials bore only that identifying number. The

consent forms were kept locked in a separate file from the measures.

MEASURES

The Center for Epidemiological Studies—Depression Scale (CES-D) was developed

as a screening instrument to detect depression in nonclinical populations. Because the items

tap few physiological symptoms (appetite, sleep, energy level, fatigue), it is well suited for

the prenatal population, in view of those symptoms being commonly associated with

pregnancy and less specific for depression (Unauthored, 1999; Beeghly et al., 2002; Besser et

al., 2002; Marcus, Flynn, Blow, & Barry, 2003). The 20 items cover the previous 7 days and

are rated on a 4-point scale. A total score is derived from summing the ratings; the score of

16 has been used as the standard cutoff point to determine distress in community samples as

well as with an obstetric population. Good internal consistency has been reported

(Cronbach’s alpha = .88-.91) in studies with perinatal women (Beeghly et al., 2002). A

threshold score of 16 or more in this study dictated the administration of The Structured

Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to review symptoms and establish

or rule out the diagnosis of depression.

The Depressive Experiences Questionnaire (DEQ) was specifically developed for

assessing dependency and self-criticism, and accomplishes this by assessing a broad range of

feelings about the self and others without overlapping with the actual clinical symptoms of

60

depression (Blatt et al., 1976). This self-report questionnaire is comprised of 66 items

inquiring about the nature of an individual’s experience of depression, and requires

approximately 15 minutes for administration. Participants identify the extent to which each

item is true on a 7-point scale ranging from (1) “strongly disagree” to (7) “strongly agree.”

Negative scores indicate low involvement on that particular factor. Subscales of the factors

are also rated and yield scaled scores. Three primary factors, Dependency (interpersonal),

Self-Criticism (self-definitional), and Efficacy are analyzed. Dependency elicits concerns

about abandonment, separation, loss, and feeling unloved. Self-Criticism reflects worries of

failure, guilt, self-definition, and unreasonably high expectations. Efficacy concerns pride,

self-confidence, self-satisfaction, and strength. Since efficacy has not been found to be a risk

factor for attachment or depression, the Efficacy scores will not be used in this study. The

mean for each factor is 0, and the standard deviation is +1/-1. Psychometric properties of

the scales are reportedly satisfactory; internal consistencies are high (Cronbach alphas > .75)

and test-retest reliabilities at 12 months are similarly high (r = .79) (Zuroff, Igreja, &

Mongrain, 1990). High convergent, construct, and discriminant validity has also been

reported (Blatt et al., 1992b). Women were designated “dependent” (anaclitic) or “self-

critical” (introjective), if their score deviated from the sample mean by one standard

deviation.

The Edinburgh Depression Scale (EPDS) is a 10-item, multiple-choice self-report

scale developed specifically for the screening and assessment of perinatal depression. The

most common tool reported in previous studies (Gaynes et al., 2005), it covers the common

symptoms of depression but excludes somatic symptoms such as fatigue and changes in

61

appetite, which occur naturally in pregnancy and would not discriminate depressed women

from non-depressed women. It takes less than five minutes to complete and has been widely

used in research and clinical practice. The split-half reliability of the EPDS has been

reported to be .88 and the standardized α coefficient 0.87 (Cox & Holden, 2003b). Scores on

this scale range from 0-30; higher scores indicate more depressive symptoms. A threshold

score of 11 or higher in this study dictated the administration of The Structured Clinical

Interview for DSM-IV Axis I Disorders (SCID-I) to review symptoms and establish or rule

out the diagnosis of depression.

The Maternal Antenatal Attachment Scale (MAAS) is a self-report questionnaire

designed to capture the developing attachment of mother to fetus (Condon et al., 1997;

Condon, 1993). Nineteen items, requiring less than 10 minutes for completion, yield data

clustered in two factors: “Quality” assesses positive emotions and thoughts regarding

closeness, tenderness, the desire to know and see the baby, as well as vivid internal

representations of the baby; “Intensity” measures the mothers’ preoccupation about the baby,

including the amount of time spent thinking about and talking to it. Prenatal attachment as

measured in this instrument has been found to fall in four quadrants, each depicting an

attachment style: strong/healthy, positive affective/low preoccupation,

uninvolved/ambivalent, and anxious, ambivalent, or affectless preoccupation. Responses are

identified on a 5-point Likert-type scale, with higher values indicating greater antenatal

attachment. In item analysis, the 19 items were reported to have an internal consistency of α

= .818.

62

The Object Relations Inventory is a method developed by Blatt and colleagues for

assessment of basic dimensions of object representations (Blatt et al., 1992a). The

participant is asked to write a description of mother and fetus. The scoring procedure

includes 12 qualitative dimensions and scores of ambivalence, complexity and conceptual

level. The 12 dimensions are Likert-style ratings of perceived personal qualities of the parent

or subject of reference: affectionate, ambitious, malevolent-benevolent, cold-warm, degree of

constructive involvement, intellectual, judgmental, negative-positive ideal, nurturant,

punitive, successful, and weak-strong. The 7-point scales are anchored at 1 = “Little” and 7 =

“Very.” A score of 9 indicates that the quality is not mentioned in the narrative and cannot

be evaluated. These 12 items produce 3 factors—Benevolent, Punitive, and Ambitious.

Ambivalence, the degree to which opposite or inconsistent feelings are expressed, is rated by

the coder on a 5-point scale anchored at 1 = “none,” 3 = “moderate,” and 5 = “large.”

Complexity refers to verbal fluency and is rated on a 7-point scale according to the length of

the description. The final score, Conceptual Level, is a five-level evaluation based on the

developmental concepts of Piaget, Werner, and others. Level One, Sensorimotor

Preoperational, is a personal, subjectively focused description that identifies the individual

primarily in terms of his/her satisfying or disappointing the subject. The second level,

Concrete-Perceptual, refers to narratives that describe the person literally, concretely,

according to external characteristics or physical properties. External Iconic, Level Three,

focuses on the person as a separate entity, describing activities and attributes that are

uniquely the person’s and not related to the subject’s gratification or frustration. Internal

Iconic, the fourth level, is coded when the description that conveys the internal state of the

63

person in such a way that the reader can empathize with the person’s experience of reality, as

the subject has done in the narrative. Conceptual Representation is the highest level and is

judged on the basis of a cohesive integration of a wide range of levels on which the person is

understood and experienced. These five levels are represented on the scale on 9 points, one

for each level and one between levels to reflect narratives that may include elements from

both levels. In the assessment of maternal representations, this open-ended instrument has

been found to be reliable (Bornstein, Galley, & Leone, 1986; Fishler, Sperling, & Carr, 1990)

and it has been utilized in a recent study of expectant mothers (Priel et al., 2001). The

inclusion of the description of the fetus was novel, as there have been no published studies in

which the instrument was used for this purpose. Coding was done by two raters, and

interrater reliability was monitored throughout the course of data gathering.

Pregnancy risk was assessed with a revision of the Hobel Risk Assessment, an

instrument assigning prescribed scores to 126 medical and obstetric risk factors of mother

and neonate (Hobel et al., 1973; Hobel, Youkeles, & Forsythe, 1979). From the original

instrument, 36 factors are intrapartum (during delivery) and 35 factors are neonatal (assessed

after the birth of the infant); these factors will not be evaluated in this study. All original

items have weighted scores based on their association with mortality, and previous studies

have fixed the score of >10 as indicative of high risk. Four additional items were added that,

while not included in the original instrument, account for a large percentage of antenatal

hospital admissions. These are premature rupture of the membrane, primary dysfunctional

labor, placenta previa, and abruption placentae. The Principal Investigator of the study, John

Rosnes, M.D., assigned weighted scores to these four items. Dr. Rosnes also categorized the

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nature of each Hobel item as primarily maternal or primarily fetal. While the chief interest

was in maternal versus fetal risk, an additional curiosity was the possible relationship

between level of risk and attachment. An analysis of risk was conducted stratifying risk into

3 categories: 1-4 = “Low risk,” 5-10 = “Medium risk,” and >10 = “High risk.”

65

CHAPTER FOUR

RESULTS

DEMOGRAPHIC INFORMATION

Unlike most previous studies utilizing largely Caucasian, middle-class, married

women, this project enjoyed a richly diverse sample. Table 1 provides the demographic

information for the sample. The sample consisted of 91 women, ranging in age from 17 to 44

years, with a mean age of 27.01 (SD = 6.44). Fifty-four percent (N = 49) were Caucasian,

33% were African American (N = 30), 11% were Hispanic (N = 10), and 2% were Asian (N

= 2). Forty-nine percent of the participants were married (N = 49), 32% were single (N =

29), 10% were living with a partner (N = 9), and 3% were separated from their husbands (N =

3). The average number of children at home was 1.02, with a range of 0 to 6 children (SD =

1.45). Eleven per cent of the sample did not complete high school (N = 10), however 25%

completed high school or had completed a General Educational Development test (N = 23),

33% received some college education (N = 30), and 26% had obtained an undergraduate or

graduate college degree (N = 24). Thirty percent had an annual household income below

$26, 000 (N = 27), 16.5% reported income of $26,000--$40,000 annually (N = 15), 16.5%

reported $41,000--$65,000 (N = 15), and 29% reported earnings of more than $65,000 a year

(N = 26). Government funds (Medicaid) covered 43% (N = 15), 48% were covered by a

private insurance plan (N = 44), and 3.3% had no coverage at the time of their admission to

Baylor (N = 3).

66

Pregnancy Characteristics

Although almost one-third of the sample was experiencing a first pregnancy (N = 29),

24% had been pregnant before (N = 22), and 44 % (N = 39) had history of at least two

previous pregnancies (Table 2). Four percent (N = 4) had suffered delivering a stillborn

baby, 27% had history of miscarriage (N = 24), and 37% had history of obstetric

complications (N = 34). Almost half of the patients were in their third trimester at onset of

obstetric complications (N = 42), but 11% (N = 10) were in their first trimester and 37% in

their second (N = 34).

Psychiatric Characteristics

As Table 3 reveals, slightly more than three-quarters of the participants denied any

history of psychiatric disturbance, hospitalization, psychotropic treatment, or counseling (N =

69), but 7% reported a history of depression (N = 6), 7% reported a history of anxiety

disorder (N = 6), 3% had been treated for both depression and anxiety (N = 3), and one

participant suffered from bipolar disorder. However, when screened for depression, 36% (N

= 33), endorsed depressive symptoms on the Center for Epidemiologic Studies- Depression

scale (CES-D; score exceeded the threshold of 16 for possible mood disorder) and 42% (N =

38), endorsed depressive symptoms on the Edinburgh Postpartum Depression Scale (EPDS).

Although 35 Structured Clinical Interviews were administered, only three patients met the

criteria for Major Depressive Disorder (six met criteria for one of the anxiety disorders).

Seventy-seven percent (N = 70), of the participants denied a familial history of psychiatric

disturbance, but 18% (N = 16), reported family history of mood, anxiety, or substance-use

disorders.

67

Nature of Obstetric Risk

There was significant variance in the severity of risk across participants in the sample

(Table 4). The mean revised Hobel Assessment score was 18.35 (SD = 9.62), with a range of

5 to 45 points. Twenty-five percent of the patients fell between 10 and 15 points of severity.

Classifying risk as “maternal” or “fetal” was not problematic; however, 42% (N = 38) of the

sample met criteria for both types of risk. This would occur, for example, when a participant

would carry the diagnosis of toxemia (severe gestational hypertension) and would also have a

history of a stillbirth and/or a premature delivery. In nine of these instances (21%), the dual

risk was due to a multiple pregnancy.

OVERVIEW OF STATISTICAL ANALYSES

Primary Hypotheses

Hypothesis One

Participants who expressed an integrated understanding of their mother’s

characteristics, qualities, and aspirations in the Object Relations Inventory (ORI) narrative

were expected to also report a higher quality and greater intensity of attachment, as evaluated

by two factors of the Maternal Antenatal Attachment Scale (MAAS). The ORI narratives are

scored on six dimensions: Benevolence, Punitiveness, Ambition, Length, Ambivalence, and

Conceptual Level. The subject’s responses on the MAAS yield a global score of attachment

as well as scores on two orthogonal factors: Quality, describing positive affect regarding the

fetus, and Intensity, reflecting the amount of time the expectant mother reports being

preoccupied with thoughts about the fetus. A one-way multivariate analysis of variance

68

(MANOVA) was conducted to determine the effect of the six dimensions of the ORI upon

the MAAS global score of attachment. The scores were separated into two levels, above and

below the mean (M = 81.5, Table 4), in the first analysis. No significant differences were

found among the dimensions for attachment, Wilks’ Λ = .899, F (6, 32) = .601, p = .728.

The multivariate η² based on Wilks’ Λ was nonsignificant, .101. Table 5 contains the means

and the standard deviations on the dependent variables for the six groups. A second

MANOVA was conducted, dividing the Global score into three groups: Lowest through -.99

sd below the mean, -1 sd through 1 sd, and 1.01 sd through the highest score. This further

stratification was also nonsignificant, Wilks’ Λ = .620, F (12, 62) = 1.393, p = .193, η² = .212

(Table 6).

A one-way analysis of variance was conducted to evaluate the relationship between

Conceptual Level of the mother narrative and the Quality of attachment score from the

MAAS. The 95% confidence intervals for the multiple comparisons, as well as the means

and standard deviations for the four Conceptual Levels, are reported in Table 7. The

independent variable, Conceptual Level of the narrative, included four levels: “Sensorimotor-

Preoperational,” “Concrete,” “External Iconic,” and “Internal Iconic” (no narratives

contained the necessary elements for the highest level, “Conceptual Level”). The dependent

variable was the Quality of Attachment score from the MAAS. The ANOVA was

nonsignificant, F (3, 79) = .434, p = .729. Figure 1 displays the distribution of the sample.

The analysis was repeated using the attachment Intensity score from the MAAS as the

dependent variable, with similar results: F (3, 77) = 1.35, p = .265 (Table 8; Figure 2). A

significant issue in the interpretation of the preceding analyses is the uneven distribution of

69

the sample across the Conceptual Level dimension of the ORI (Table 9). In view of this

limitation, several other analytical strategies were employed.

Correlation coefficients were computed among the Quality of Attachment factor, the

Intensity of Attachment factor, and only the Conceptual Level of the mother narrative (Table

10). Since the Conceptual Level score is ordinal, Spearman’s rho was computed for this

comparison. The results of the correlational analysis were nonsignificant (.02 for Quality

and -.210 for Intensity). See Figures 3 through 5 for distributions of Conceptual Level across

the MAAS Quality, Intensity, and Global scores.

In the following analysis, the ORI scores for Conceptual Level were collapsed into

two groups: Participants with narratives in the Sensorimotor-Preoperational and Concrete

levels were combined and those with narratives in the External and Internal Iconic level were

combined. A two-way contingency table analysis was conducted to assess whether there

were differences in the Quality of Attachment factor between the two levels of narratives

(Table 11). The Quality scores were divided above and below the mean and, once more, test

results were nonsignificant: Pearson χ² (1, N = 83) = .855, p = .465. A second analysis was

undertaken, forming three groups of attachment scores: “Low,” lowest through -.6,

“Average,” -.5 through .5, and “High,” .6 through the highest score (Table 12). (Since there

were no scores greater than +1 standard deviation from the mean it was necessary to choose

.5 as the point for analysis.) The test statistic changed slightly: Pearson χ² (2, N = 83) = .111,

p = .946 and, once again, the problem of unbalanced distribution across the groups of

attachment calls for caution in interpretation.

70

These two analyses were repeated exploring the relationship between MAAS

Intensity of Attachment scores and Conceptual Level of the mother narrative. The first two-

way contingency table analyzed two levels of object representation Conceptual Level,

Preoperational/Concrete and External/Internal Iconic, and two levels of Intensity, above and

below the mean. Table 13 displays the nonsignificant results: Pearson χ² (1, N = 81) = .173,

p = .727. The second analysis repeated the stratification of Conceptual Level and also

stratified Intensity into three levels: “Low” (lowest through -.6), “Average” (-.5 through .5),

and “High” (.6 through the highest score). These nonsignificant findings appear in Table 14:

Pearson χ² (1, N = 81) = 2.04, p = .361. In light of these findings, no further analyses were

performed. The results suggest that the participants’ mental representations of their mothers

were not related to the quality or intensity of antenatal attachment as evaluated by the

MAAS.

Hypothesis Two

Originally, it was also proposed that these same analytic procedures would be carried

out with participants’ narratives about their fetuses. However, in scoring the narratives it

became apparent that the twelve characteristics from which the Benevolent, Punitive, and

Ambitious dimensions are derived were not appropriate for a narrative about an unborn baby.

Three dimensions, Ambivalence, Length, and Conceptual Level, were retained for analysis,

and a MANOVA was conducted with these dimensions and the MAAS Global Attachment

score (once again divided into an “Above the Mean” group and a “Below the Mean” group).

A significant difference between the groups was found, Wilks’ Λ = .843, F (3, 81) = 5.031, p

= .003, η² = .157. Means and standard deviations are contained in Table 15. Analyses of

71

variances (ANOVA) on each dimension were conducted as follow-up test to the MANOVA.

The ANOVA on the Ambivalence dimension was significant, F (1, 83) = 11.12, p = .001, η²

= .118, while the ANOVAs on the Length, F (1,83) = .026, p = .873, and Conceptual Level,

F (1, 83) = .003, p = .958, were nonsignificant. When subjected to the same second analyses

with the Global Attachment score categorized in three levels, the significance remained;

Wilks’ Λ = .769, F (6, 160) = 3.735, p = .002, η² = .123 (Table 16). In the follow-up

ANOVAs on each dimension, the statistic on Ambivalence increased in significance, F (2,

82) = 8.52, p = .000, η² = .172. Baby narrative Conceptual Level and Length remained

nonsignificant. These findings suggest that mothers who express ambivalent feelings about

their babies have slightly lower Global scores of antenatal attachment.

It was hypothesized that women who could articulate more complex representations

of their mothers would also be able to do so of their babies, as evaluated by the Conceptual

Level dimension of the ORI. Taking into consideration the ordinal quality of the measures, a

Spearman’s rho analysis was performed and no significant association between the

Conceptual Levels of the two narratives was suggested, r = .068, p = .55. Figure 6 illustrates

the distributions of Conceptual Levels of the two narratives. Two other dimensions of the

two narratives, Ambivalence and Length, were also compared. The results of the

correlational analyses presented in Table 17 show that 8 out of the 15 correlations were

statistically significant, ranging from r = .27 to r = .72. All significant correlations were

related to Ambivalence or Length, one of which was associated with Conceptual Level. The

findings seem to suggest that women who express ambivalence toward their mothers also

express it of their babies, and these narratives tend to be more fluent than those in which no

72

ambivalence is scored. The length of the baby narrative was positively associated with the

Conceptual Level of the baby narrative, perhaps not surprising in that higher Conceptual

Levels would require greater articulation.

Two bi-level variables were created by collapsing the Conceptual Levels of mother

and baby narratives into two categories, Preoperational/Concrete and External/Internal

Iconic. A two-way contingency table analysis was conducted to evaluate whether there were

associations between these broader categories of representation. The results of the test were

nonsignificant, Pearson χ² (1, N = 82) = .206, p = .695 (Table 18). Although the two

narratives may resemble one another in terms of Ambivalence and Length, the findings do

not support any association on the dimension of Conceptual Level.

Hypothesis Three

According to Condon’s model of antenatal attachment, expectant parents resided in

one of four quadrants of attachment style, estimated by the scores on the Quality and

Intensity factors (Condon, 1993). The final stated expectations of the primary hypotheses

were that dependent tendencies would be more highly associated with an anxious, ambivalent

style of prenatal attachment as conceptualized in the fourth quadrant of the MAAS

Attachment Style paradigm. Self-critical tendencies, as identified by scores above the mean

on the Depressive Experiences Questionnaire (DEQ) were expected to be more highly

associated with a high quality of attachment but an avoidant style (second quadrant).

Blatt’s original scoring method of the DEQ (raw scores are transformed into z scores,

weighted according to the factor they are most highly correlated, and summed) was

employed for these analyses (Blatt et al., 1976). Means and standard deviations of the DEQ

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are located in Table 4. First, a Pearson’s product-moment correlation was performed

between the DEQ z scores for dependency and self-criticism and the MAAS Global, Quality,

and Intensity of Attachment scores (Table 19). The self-critical scale of the DEQ was

negatively correlated with the MAAS Quality of Attachment factor (N = 91; r = -.366, p <

.000), but analysis revealed no significant association between the self-critical scale and the

MAAS Intensity of Attachment factor. Dependency was not found to correlate with either

the quality or intensity of attachment.

In the next analyses, participants were identified by one of Condon’s quadrants

according to their scores on the Quality and Intensity factors of the MAAS. Following

Condon’s theoretical framework, four categories were established: Quadrant One, high

Quality and high Intensity (strong, secure) ; Quadrant Two, high Quality and low Intensity

(avoidant); Quadrant Three, low Quality and low Intensity (withdrawn); and Quadrant Four,

low Quality and High Intensity (anxious, ambivalent). Quality and Intensity were rated

“high” when above the mean of the sample and “low” when below the mean. Figure 7

portrays the distribution of the sample according to Condon’s formulation. In order to

identify highly dependent or highly self-critical individuals from the DEQ scores, it had been

proposed that the sample be divided into individuals within and outside of two standard

deviations of the mean. After the data were collected, it became apparent that this strategy

was not the best way to analyze the data because of the homogeneity of the scores.

Therefore, differences of greater or less than one standard deviation on the DEQ scores

established three categories of the Self-critical style (M = -.93, SD = 1.01) and Dependent

style (M = -.53, SD = .90). (Categories were “Low” < -1 standard deviation from the mean,

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“Average” > -1 but < 1 standard deviation from the mean, and “High” > 1 standard deviation

from the mean. A contingency table analysis was then conducted to investigate whether

pregnant women who are more self-critical reported a higher quality of attachment but a

lower intensity (Quadrant Two). A Pearson χ² analysis was nonsignificant, (6, N = 91) =

5.714, p = .456. However, the sample size was not large enough to afford a valid

interpretation (Table 20). Therefore, the Self-Criticism factor was condensed to two levels,

below and above the mean (M = -.93). The sample still lacked power, however the Pearson

χ² was significant, (3, N = 91) = 8.93, p = .03, η² = .21 (Table 21). Nevertheless, a look at the

sample reveals that those individuals who are more self-critical are less likely to reside in the

Avoidant quadrant than in the other three. It is unlikely, even with greater power, the

hypothesis would be supported.

The same approach was attempted with Dependency scores. In this sample, so few

participants scored in the average range of DEQ Dependency that the resulting Pearson chi-

square analysis cannot be interpreted (Table 22). The second analysis, identifying subjects as

above or below the mean on the Dependency factor, improved the distribution of the sample,

but those who endorse dependent statements do not appear to have a clear preference for any

of Condon’s four quadrants (Table 23). Although the analyses are somewhat underpowered,

these findings suggest that women who are more self-critical report a lower quality of

attachment and trend toward the third (withdrawn) and fourth (anxious ambivalent) quadrant

attachment styles in Condon’s model. There appear to be no significant differences in the

level of attachment intensity such women report. On the other hand, the attachment scores of

women who are more dependent do not to fit clearly into any of the Condon quadrants.

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Hypothesis Four

It was further expected that women with a self-critical personality style would convey

object representations of a higher Conceptual Level and report a higher quality of attachment

than women with a dependent style. Once again, the distribution of the sample across the

categories did not allow for a valid analysis of four Conceptual Levels of the narrative by

self-criticism or dependency in three categories, Low, Average, and High (Tables 24 and 25).

Even when stratifying the narrative Conceptual Level into two levels

(Preoperational/Concrete and External/Internal Iconic) and the DEQ Dependency and Self-

Critical factors above and below the mean (Tables 26 and 27; Figures 8 and 9), the sample

does not distribute as expected, and is not significant. For the Self-Critical model, the

Pearson χ² (1, N = 83) = 1.51, p = .272; for the Dependent model, the Pearson χ² (1, N = 83)

= 1.32, p .284. However, the data trend toward a refutation of the original hypothesis.

Secondary Hypotheses

Hypothesis Five

The secondary hypotheses are to be viewed as exploratory. Firstly, it was

hypothesized that fetal representation and attachment might be influenced by the type of risk

(maternal, fetal, or combined) described to the patient by her obstetrician. A one-way

analysis of covariance (ANCOVA) was conducted. The independent variable, Conceptual

Level of the ORI, included two levels: Preoperational/Concrete and External/Internal Iconic.

The dependent variable was the MAAS Global attachment score and the covariate was risk.

The ANCOVA was non significant, F (1, 82) = .05, MSE = 2.49, p = .823. Holding risk

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constant, there was no relationship between Conceptual Level of the baby narrative and the

Global attachment score.

Secondly, it was expected that those mothers identified as being hospitalized for

significant risk of fetal demise would report higher antenatal attachment, as indicated by the

global score of the MAAS, than mothers hospitalized because of significant maternal risk

factors. The risk factors of the revised Hobel scale as identified primarily “fetal” or

“maternal” are listed in Tables 28 and 29. A one-way analysis of variance was conducted to

evaluate the relationship between type of risk and attachment. The independent variable,

type of risk, included three levels: fetal, maternal, and both fetal and maternal. The

dependent variable was the change in the Global score of the MAAS. The ANOVA was

nonsignificant, F (2, 90) = .436, p = .648. The means and standard deviations for the three

types of risk are reported in Table 30 and portrayed in Figure 11. Since the third group

incorporates fetal risk, the three groups were combined into two groups, maternal and

fetal/combined maternal-fetal. Another one-way analysis of variance was conducted and was

also nonsignificant, F (1, 90) = .04, p = .841. The means and standard deviations for the two

groups are reported in Table 31. These results suggest that the type of obstetric risk has little

association with mental representation or reported attachment.

Hypothesis Six

It was expected that mothers with identified fetal risk would report a greater intensity

of antenatal attachment. First, a one-way analysis of variance was performed with the

MAAS Intensity score as the dependent variable and type of risk the independent variable

(means, standard deviations, and pairwise comparisons appear in Table 32). The ANOVA

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was nonsignificant, F (2, 86) = 1.239, p = .295. A two-way contingency table analysis was

then conducted with three levels of risk, maternal, fetal, and fetal-maternal, and two levels of

Intensity, above and below the mean (N = 89, M = 30.71, SD = 4.88). Fetal risk and intensity

of attachment were nonsignificantly related, Pearson χ² (2, 89) = 1.36, p = .506 (Table 33).

The MAAS Quality factor and Global score were also analyzed in this manner, with no

significant findings (Table 33). The analyses were repeated collapsing risk into two

categories, maternal and fetal/combined maternal-fetal. The results remained nonsignificant,

Pearson χ² (1, 89) = .048, p = 1.00 (Table 34). A Pearson’s product-moment correlation was

performed for risk severity (represented as the sum of Hobel weighted risk items) and the

three MAAS scores (Quality, Intensity, and Global). Table 35 reports the values. A one-way

analysis of variance was also executed placing the MAAS Intensity score as the dependent

variable and the level of risk as the independent variable (means, standard deviations, and

pairwise comparisons appear in Table 36). The statistic, F (2, 86) = 1.25, p = .293, was

nonsignificant. From these analyses, there does not appear to be a significant relationship

between type of risk or level of risk severity and intensity of attachment as measured by the

MAAS.

Hypothesis Seven

It was hypothesized that older gestational age of the fetus (calculated in weeks) at the

time of admission to the antenatal unit would be positively correlated with the Global

attachment score of the MAAS. A Pearson’s product-moment correlation was employed to

assess this relationship and was also nonsignificant, so this hypothesis is disproved. Table 37

reports the correlations and probabilities.

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Depression and Attachment

As reviewed earlier, depression and antenatal attachment have been linked by

numerous previously published studies. The data from this population support those

findings. Both screening measures, the Edinburgh Postpartum Depression Scale (EPDS) and

the Center for Epidemiologic Studies-Depression scale (CES-D) were negatively correlated

with the Quality of Attachment factor from the MAAS (Table 36). The screening measures

do not have a significant correlation with the Intensity factor, and only the EPDS is

significantly correlated with the Global score.

In order to examine this association more closely, a univariate analysis of variance

was conducted with the EPDS score as the dependent variable and attachment style as the

independent variable. The F ratio was significant, 8.693 (3, 87), p = .000, and the

relationship strong, as assessed by η², with the Quality of Attachment score accounting for

23% of the variance of the dependent variable. Post-hoc tests were performed to evaluate

pairwise differences among the means (Table 40). There was a significant difference in the

means between the groups that reside in the High Quality quadrants of Condon’s attachment

style framework. Those participants who were above the mean on the Quality factor reported

fewer depressive symptoms than those who were below the mean and in the two Low Quality

quadrants of the model. A second analysis confirmed the findings, Pearson χ² (3, 91) =

21.339, p = .000. This relationship was stronger than that reported in the ANOVA (η² = .39).

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Exploratory Analyses

DEQ: As some have been concerned with the use of factor-derived scale scores in the

original scoring system of the DEQ, several analyses were run on the variables of interest

utilizing other scoring procedures of the instrument (Bagby et al., 1994; Rude & Burham,

1995; Santor, Zuroff, & Fielding, 1997a; Blatt et al., 1995). Bagby et al. proposed a

shortened scale in which items with excellent fit to the two-factor model (Dependency and

Self-Criticism) were isolated (1994). Blatt and colleagues identified two “facets” of the

Dependency factor that suggested two different levels of interpersonal functioning:

“Dependence,” derived from items that endorsed feelings of helplessness, broad

apprehensions about rejection or fears of separation and loss not related to a specific

individual, and “Relatedness,” the product of items that consider feelings about the loss or

loneliness that might occur as the result of disruption in a relationship with a particular

significant person (1995). Rude and Burnham theorized that dependency was not entirely

pathological, and that the Dependency scale of the DEQ could be divided into the subscales

“Connectedness” and “Neediness” (1995). Connectedness referred to healthy valuing of

relationships and neediness applied to the pathological anxiety concerning rejection and loss.

Santor et al. introduced a shortened instrument that utilizes the preferred unit-weighted

composite scoring system yet preserves the orthogonality of the factors found in the original

scoring system (1997).

First, Pearson’s product-moment intercorrelations were computed for the sample

across all four scoring systems. Table 42 reports the means and standard deviations for the

sample and Table 43 reports the intercorrelations. As would be expected, the scoring

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systems are highly correlated; out of 28 correlations, 14 exceed r =.60, and only 5 are

nonsignificant. Note both the original scoring and the McGill scoring of the Self-Criticism

factor are not associated significantly with Rude & Burnham’s “Connectedness” aspect of

Dependency but are moderately associated with the “Neediness,” the less healthy aspect of

interpersonal functioning.

Second, Pearson product-moment correlations between MAAS attachment scores and

the three revised scoring system were conducted (Tables 44-46). The Self-Critical factor, as

scored in the McGill system, is negatively related with Quality (r = -.339, p < .01). Blatt’s

revised subscale of Dependency, Relatedness, is negatively associated with Quality (r = -

.241, p < .05) and Rude & Burnham’s subscale, Neediness, is also negatively associated with

Quality (r =-.242, p < .05).

Finally, a series of regression analyses were then conducted to compare to what

extent each scoring method of dependency and self-criticism scores could predict the MAAS

Global Attachment score. The predictors were the eight scores (original, McGill, Blatt

revised, and Rude and Burnham revised), and the criterion variable was the overall measure

of attachment provided by the MAAS. Out of four analyses, no linear combination of

dependency and self-criticism scores proved to be significantly related to the attachment

index. Table 47 contains reports the results.

Gestational age: Other investigators, as cited in the literature review, have found

relationships between attachment and gestational age, particularly after quickening. No such

relationship was found in this population in a Pearson product-moment correlation of

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gestational age (weeks) and MAAS Global Attachment score (r = .135, p = .203), Quality of

Attachment (r = .08, p =.45), or Intensity of Attachment (r = .157, p .142).

Object Relations Inventory: The use of the Object Relations Inventory in assessing

the maternal-fetal relationship is as yet unpublished. To explore a possible relationship

between the baby narrative and gestational age, a Spearman’s rho correlation was conducted

and no significant associations were found (Table 48). Multivariate analyses of variance

were also conducted on the Length, Ambivalence, and Conceptual Level dimensions of the

mother and baby narratives across ethnicity, with nonsignificant results: Wilks’ Λ = .77, F

(18, 204) = 1.09, p = .368. Pearson’s product-moment correlations were performed between

age and the above dimensions. All correlations were nonsignificant with the exception of

ambivalence in the mother narrative, r = .230, p <.05. Within this sample, younger women

revealed more ambivalent feelings in the narratives about their mothers than did older

participants.

Another analysis explored the possibility of a relationship between the baby narrative

and having other children. A Pearson’s product-moment correlation was conducted between

“number of children at home” and the Conceptual Level of the ORI. There was no

significance: r = -.054, p = .627.

Maternal Antenatal Attachment Scale: Table 39 reports an interesting positive

correlation between age and Quality of attachment (r = .29, p < .01). This finding suggests

that older women report a higher quality of attachment than do their younger colleagues. A

second exploration investigated parity, however a two-way contingency table found no

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significant difference in Global attachment scores of multiparous women and primagravidas,

Pearson χ² (1, 88) = 2.69, p = .10.

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CHAPTER FIVE

Conclusions and Recommendations

The purpose of the present investigation was to delineate the convergence of

personality, object representation, and antenatal attachment in the context of significant

maternal or fetal risk. Previous research in general populations has associated depression

with the personality tendencies of dependency and self-criticism, and also with lower levels

of development in object representation. As these relationships have been investigated in

women during the perinatal period, findings have suggested that not only are there

relationships between personality, object representation, and depression, but depression often

impinges upon the natural process of maternal attachment to baby (Priel et al., 2001).

Depression and attachment seem to have a reciprocal relationship, for other research has

suggested that strong antenatal attachment acts as a protective factor against postpartum

depression (Priel et al., 1999). Most prior research has focused on uncomplicated

pregnancies in a Caucasian, middle-class, married population, however studies that have

included women with elevated obstetric risk have suggested that such risk may be both a

moderate predictor of postpartum depression and a risk factor for healthy antenatal

attachment. This study attempted to assess the variables of personality, object representation,

and maternal/fetal risk with the expectation they would have heuristic value in predicting

antenatal attachment and clinical value in identifying those women at risk for postpartum

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depression. The knowledge of significant risk in the hospital environment was expected to

interact with these other factors by increasing the level of attachment to the fetus that

hospitalized women report.

CHARACTERISTICS OF THE SAMPLE

Demographic Qualities

In addition to their hospitalization, the 91 women who participated in this research

were quite different from the sample groups of previous studies. Almost half of the

participants were not Caucasian, however the percentage of Caucasian patients who

participated in the research is congruent with the general population of the Dallas area

(53.8% versus 59.1%). The sample percentage of Hispanic patients is slightly smaller (11%

versus 35.6%) and the number of African American patients is slightly higher (33% versus

20.3%) than the Dallas demographic (2004 Dallas Community Census). Previous research

done in this country has been done with samples that were predominantly Caucasian: Studies

utilizing high risk samples like those of Gupton (77.9%) and Maloni (94%) have to this date

underrepresented other ethnicities (Gupton et al., 2001; Maloni, Brezinski-Tomasi, &

Johnson, 2001).

Participants’ average age was 27 years, with a range of 17 to 44. This sample was

slightly younger than other research with high risk populations (Gupton reported a mean age

of 29.27 and Maloni reported 31.2) as well as with samples of women with uncomplicated

pregnancy (Zimmerman and Doan reported 30.06 and Lindgren reported 29.5) (Zimerman &

Doan, 2003; Lindgren, 2001).

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Socioeconomic status was balanced: 24% reported less than $25, 000 in household

income, 35% reported between $26,000 and $65,000, and 29% exceeded $66,000 annually.

In comparison to Gupton’s sample, this group is somewhat wealthier (Maloni did not report

income). Educational attainment was also well represented. Eleven percent of the sample

did not finish high school, but 25% graduated or received a GED, 33% had some college, and

26% had an undergraduate/graduate degree. Ninety-four percent of Maloni’s sample had

some college (Gupton did not report education), but this is not representative of the Dallas

demographic. According to the 2004 Dallas Community Survey, 76% of Dallas County

residents 25 years and older are High school graduates and 28% have a Bachelor’s degree or

higher. The 91 women included in this research represent the area population fairly well.

According to Cornell University New Service, out-of-wedlock births accounted for

one-third of all U. S. births in 2003, exactly the same ratio of unmarried participants in this

study (Lang, 2005). Sixty-five percent were married or were cohabiting. This also

distinguishes the sample from previous psychosocial studies, as most of the participants in

other samples have been married (Gupton, 85.6%; Maloni, 92.1%).

Pregnancy-Related Qualities

Another distinctive quality of this sample is the range of new mothers to primaparous

mothers. Thirty-two percent of the sample was experiencing a first pregnancy, 24.4% were

experiencing their second, 22% their third, and 21.6% had a range of four to seven previous

pregnancies. Fifty-three percent of Gupton’s participants were pregnant for the first time,

and Lindgren reported her sample as being 41% primaparous. Maloni, in her discussion of

the impact of bed rest upon the families of her participants, reported that 45 of the 89 women

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had other children. In this sample, 54.9% of the women had at least one child at home (33%

had two children, and 15% had from three to six children in the household).

Psychiatric Qualities

Although psychiatric illness was not a specific interest in this study, it is of interest to

compare the prevalence rates of depression and anxiety published in the Diagnostic and

Statistical Manual of Mental Disorders with the rates found in this sample of women (2000).

Almost seven percent of the sample had history of being diagnosed with depression (point

prevalence in community samples is 5-9%), and the same number reported receiving a

diagnosis of one of the anxiety disorders (one-year prevalence rate in community samples is

5%). Three percent reported a dual diagnosis (community rates are around 10%), and one

participant had previously been diagnosed with bipolar disorder (lifetime prevalence

approximately 0.5%). Almost 42% of the women scored at or over the threshold (score of

11) of the Edinburgh Postpartum Depression Scale (EPDS), and 44% scored at or over the

threshold (score of 16) on the Center for Epidemiologic Studies-Depression scale (CES-D)

provoking the administration of the Structured Clinical Interview for Diagnosis of Axis-I

Disorders (SCID). Yet of these administrations, although two participants fully met the

criteria for a dual diagnosis of Major Depressive Disorder and Generalized Anxiety Disorder,

none met the criteria for a diagnosis of depression alone. Although it is beyond the scope of

this discussion, this is a common finding due to the difficulty of choosing a threshold score

on depression screening instruments with the acceptable balance of specificity and sensitivity

(Austin & Lumley, 2003; Cox & Holden, 2003a). In Austin and Lumley’s review article of

antenatal screening research, four out of sixteen published studies reported similarly high

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percentages of subjects exceeding the threshold. One possible explanation for the

discrepancy between positive screenings for depression and negative diagnoses in this

sample pertains to the DSM-IV criteria for Major Depressive Disorder. The EPDS instructs

the subject to answer the questions based on how she has felt over the last seven days,

however the DSM-IV criteria require that the depressive symptoms have been in place for

most of the day over the previous two-week period. The participants in this study completed

the questionnaire within the first 72 hours of hospitalization; the clinical interviews were

usually administered at a later point, dependant upon patient and research investigator

availability. Often patients would report that they had been upset initially upon

hospitalization but were “feeling better now that things have settled down.”

Varieties of Obstetric Risk

The Hobel Risk Asssessment system includes 51 antenatal maternal and fetal risk

factors (Tables 28 and 29). Its design was to enable an assessment of prematurity probability

(Hobel et al., 1973). However, the original instrument did not include in the prenatal

inventory four conditions that often present in hospital admission for obstetric risk:

Premature rupture of the membranes, preterm labor, placenta previa, and placental abruption.

In this study, these four common diagnoses were included in the risk assessment, and

weighted for severity by the Principal Investigator of the study, obstetrician John Rosnes.

Three studies provide interesting comparisons of common risks (Table 49). Perhaps

Gupton’s study is the most similar in context, for it included 105 women hospitalized for

more than 48 hours. Maloni’s study sample consisted of 89 women prescribed antepartum

bed rest in the hospital or at home, and participants in Besser’s study were not hospitalized.

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However, there are significant differences across these three samples, testifying to the

difficulty of comparing this sample with others in the population.

DISCUSSION OF FINDINGS

Maternal Object Representation and Maternal Antenatal Attachment

A previous investigation found significant associations between antenatal attachment

and object representation (Priel et al., 2001), but the data from this sample does not support a

relationship between the two constructs. Multiple statistical analyses, both parametric and

nonparametric, were employed manipulating the sample in several configurations and all

failed to reach significance. Contrary to the hypotheses, it is intriguing that the MANOVA

procedures examining the Maternal Antenatal Attachment Scale (MAAS) scores of Quality,

Intensity, and Global attachment across the Conceptual Levels of the narratives consistently

associated lower attachment scores to the participants rated the highest in developmental

level on the Object Relations Inventory (ORI) narratives. This nonsignificant trend is an

example of the hazard of sampling error, for only eight subjects fell in the lower two levels

of development (Sensorimotor/preoperational and Concrete) in the mother narrative as

opposed to 75 found in the two higher levels of development (External and Internal Iconic).

Although the sample reached the stated minimum of 90 subjects, the power was insufficient

for confidently detecting differences in some analyses, particularly those involving the six

dimensions of the ORI. Nevertheless, this study was an effective pilot in terms of exploring

trends or signals.

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Priel and Besser employed both the ORI and the MAAS in a study of 120 Israeli

women with uncomplicated pregnancies and a mean age of 25.21 (SD = 3.50; Priel et al.,

2001). Table 50 displays a comparison of the ORI and MAAS means and standard

deviations from their sample with those of this work. The statistics of the two samples

overlap in each score with the exception of “Punitive.” In regard to the attachment measure,

the Quality score means are within one point of one another, while the Baylor sample

Intensity means exceed those of the Israeli sample by three points. Priel and Besser were

able to report significant correlations between each ORI dimension and Quality of

attachment, as well as a significant correlation between Conceptual Level and Intensity of

attachment. Table 51 compares the correlations of the two samples. A primary difference

between the two samples is the presence of obstetric risk in the Baylor subjects, but the

differences in findings are more likely a product of discrepant sample sizes (the Israeli study

included 120 participants, 45% more than the Baylor sample).

In the absence of relationships between the ORI dimensions and the MAAS scales,

there are some interesting relationships within the ORI. One rather strong association found

in the mother narrative is that between the characteristics of Ambivalence and Length (r =

.40, p = .000). The scoring manual of the ORI directs Ambivalence to be evaluated by the

degree to which the subject relates opposing feelings about the “other,” or expressing

confused, mixed feelings. Length is evaluated by counting the lines in the narrative. In

taking a look at the specific narratives with high ambivalence scores, it clearly takes more

fluency for the subject to express the confusion. One narrative demonstrates this vividly:

My mother just turned 44 years old this month. She is also the mother of ten children, but if it weren’t for abortion and miscarriges (sic) she would probably

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have 25 kids. She had me at the age of 16 and I was raised by my grandmother. My mother has never really had a job for a long time but she is very educated. She as attained several different degrees and not once put one to use. I sometimes believe that she has multiple personalities but she does have a good heart and you just have to know her to love her.

Ambivalence is also strongly negatively related to Benevolence (r = -.41, p = .000) and has

an even stronger positive correlation with the Punitive descriptive (r = .66, p = .000), further

explaining the nature of confusing feelings about the other.

Object Representation of Mother and Baby

One adventure of this study has been the exploration of the ORI narrative of the fetus.

The assumption was that women who had the capability of expressing complex highly

developed narratives about their mother would be able to do the same about their unborn

child. This was to be evaluated by a comparison of the Conceptual Levels of the two

narratives. This proved to be difficult in data collection, for few narratives about babies

could meet the criteria for the higher conceptual levels. Describing the fetus in

preoperational symbiotic language, concrete literal terms, or by fetal movement and activity

was dominant. Attributing thoughts, feelings, values, or understanding the baby on a wide

range of levels was less often noted. (See Table 9 for the frequencies of Conceptual Levels

in both narratives.) There was no significant association between this characteristic of the

two narratives. However, there were associations in the other dimensions of the scale. The

Conceptual Level of the baby narrative was associated with the length of the mother

narrative. Additionally, the length of the baby narrative was positively correlated with length

of the mother narrative (r = .720, p = .000), and ambivalence in both narratives. As pointed

out in the previous section, some scoring requires the subject to write more about the person,

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so these relationships of length may be more functional than psychologically revealing. The

ORI has been validated in a number of populations and has no reports of level of education

biasing the narratives, but an analysis of this sample was performed for confirmation. A two-

way contingency table analysis failed to find significant differences in either the baby or

mother narratives according to educational level.

Another consideration is whether the baby narrative is actually capturing the mother’s

internal representation of her baby or her ability to imagine her baby. This would not be

contradictory to the theoretical stance that object representations differ from internal working

models in the respect that they introduce wish and fantasy into the mental representation of

the relationship. The fantasies of pregnant women have been alluded to in other antenatal

research; in fact, the absence of antenatal fantasy has been considered dysfunctional (Cohen,

1979; Grace, 1989; Cranley, 1981; Leifer, 1977). In one investigation, 184 pregnant women

were asked, “Please write a few sentences about what you expect your baby to be like”

(Sorenson & Schuelke, 1999). The responses were analyzed by a series of iterations that

ultimately identified ten major themes: Appearance, psychological traits, gender, behavior,

normalization, deification, role relations, impact on parents, spiritual, and ambiguity.

Findings indicated that fantasies tended to develop across gestational age and differed

between multiparas and primigravidas, with multiparous women seeming to be significantly

influenced by their older child. In investigation of this sample, however, no differences in

Conceptual Level of the ORI were found between women who had children at home and

first-time mothers.

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Dependency, Self-Criticism, and Antenatal Attachment

In studies of romantic attachment in adult samples, dependency has been associated

with an anxious-ambivalent style and self-criticism with a fearful, avoidant style (Besser et

al., 2003a) (Zuroff et al., 1995). Similar findings resulted from research conducted with a

sample of women in uncomplicated pregnancy (Priel et al., 1999). Therefore, it was

expected that dependency in this sample would be related to Condon’s anxious ambivalent

antenatal attachment style (low quality, high intensity) and that self-criticism would be

associated to the avoidant antenatal attachment style (high quality, low intensity; Condon,

1993). A larger sample may have produced significance; however, the trend suggests that the

hypothesis would be disproved even in a larger sample. Those scoring over the mean of the

sample for dependency were fairly equally distributed throughout the four attachment styles.

Out of 39 individuals who scored above the mean for self-criticism, only three resided in the

Avoidant quadrant, whereas the other 36 participants were fairly evenly distributed across the

remaining three antenatal attachment styles.

A question that appears in this analysis is the suitability of the MAAS for this type of

exploration. First, it is possible that the Quality and Intensity scales of the MAAS are not

sufficiently orthogonal to produce the four theorized styles. Second, some of Condon’s

predictions regarding the scale are not confirmed in the sample. For example, he proposed

that multiparous women may be overrepresented in the second quadrant, Avoidant, due to a

lack of time in “attachment mode.” Analyses in this study found no differences between

multiparous and nulliparous women.

93

Self-Criticism, Dependency, and Object Representation

It was predicted that women with a self-critical style would convey maternal object

representations of a higher conceptual level and report a higher quality of antenatal

attachment than women with a dependent style. Only eight subjects responded with

narratives in the lower two conceptual levels opposed to 75 who were rated in the higher two

conceptual levels. Although the differences were not significant, it is noteworthy that

dependent and self-critical styles in the two-way contingency tables (Tables 26 and 27) are

exactly opposite in their placement. Those who are less self-critical tend to provide

narratives of higher conceptual levels, whereas those who are more dependent express

maternal representations of a higher level.

Also, the self-critical type failed to report a higher quality of attachment than the

dependent type. Self-criticism was, in fact, significantly negatively associated with Quality

of attachment (r = -.37, p <.000). This result is interesting in relation to Priel and Besser’s

finding that highly self-critical subjects’ risk for depression was lowered if they became

strongly attached to the fetus during pregnancy. If self-criticism is associated with a lower

quality of antenatal attachment, but attachment can reduce vulnerability to postpartum

depression, an interesting paradox exists.

Risk and Attachment

Previous research has been equivocal concerning the impact of risk on maternal fetal

attachment. Findings from this sample are not ambiguous—they are simply negative. A

number of statistical analyses investigating both type of risk (maternal, fetal, or combined)

and level of risk (low, medium, and high, calculated by the mean of the Hobel Risk

94

Assessment scores of the sample) failed to find any significant relationships between risk,

attachment, and object representation in this sample. Ruling out measurement error, it is

possible that the level or type of risk is not strong enough to affect differences in antenatal

attachment in the women in this sample (Cannella, 2005).

Depression

Both screening measures, the CES-D and the EPDS, were significantly correlated

with the Quality scale of the MAAS. However, only the EPDS was significantly associated

with the Global score, and neither instrument was associated with the Intensity scale. It

would be interesting in future research to investigate any potential associations between the

Intensity of Attachment factor and screening instruments designed for the spectrum of

anxiety disorders. Both screening instruments were significantly correlated with the

Dependency and Self-Criticism scales of the DEQ. However, neither instrument was

associated with the severity of risk.

Exploring the attachment styles of mothers who scored above and below the threshold

for possible depression on the EPDS depression instrument exposed an interesting and

significant relationship between depressive symptomatology and attachment quality. Table

41 portrays mothers over the threshold score of 11 as residing in the third (withdrawn) and

fourth (anxious ambivalent) quadrants of Condon’s model. This is consistent with previous

research referring to the tendency for depressed mothers to be withdrawn from their infants,

at great cost to the child (Dawson, Klinger, Panagiotides, Hill, & Spieker, 1992; Murray,

1992).

95

Alternate Scoring Methods for the DEQ

As mentioned in the results, psychometricians have concerns regarding the standard

scoring system utilized for the DEQ (Santor et al., 1997a; Bagby et al., 1994). In addition, a

growing movement within the domain of feminist psychology has questioned the assumption

of dependency as a maladaptive style of interpersonal relatedness (Rude et al., 1995).

Several theorists, Blatt and the fellow authors of the DEQ included, have suggested that the

Dependency scale might actually be composed of two subscales, a “healthy” one and an

“unhealthy” one. This has led to revisions of the scoring system and new subscales of

“Relatedness” and “Dependency” (Blatt et al., 1995; Bacchiochi et al., 2003) and

“Connectedness and Neediness” (Rude et al., 1995). Advocates of this stance believe this

distinction between the psychologically adaptive maintenance of close, reciprocal

relationships and the pathological fearful, helpless, and clinging approach to others may

explain why often those who score highly in Dependency are less vulnerable to depression

(McBride, Zuroff, Bacchiochi, & Bagby, 2006; Besser, Flett, & Davis, 2003; Zuroff et al.,

1995). As seen in Table 43, the samples’ DEQ scores were calculated by each method and

then compared for associations. Of note are the positive correlations between the two Self-

Criticism scores and Rude and Burnham’s Neediness subscale, and the lack of association

between the Self-Criticism scores and the Connectedness subscale. The difference, while

still significant, is not so striking when comparing Blatt’s subscales, Dependency and

Relatedness, with the standard scales. This generates the question of what is being measured,

personality tendencies or a vulnerability to depression that transcends self-criticism or

dependency?

96

When testing the other scoring methods for associations with attachment, there are

significant findings. The McGill scoring system produces the same negative correlation

between Self-Criticism and Quality of attachment (r = -.339, p < .001), as the standard scale

(r = -.336, p <.000), and correlations between Dependency, Intensity of attachment, and

Global attachment are all nonsignificant. Blatt et al’s subscale Relatedness (the healthy,

mature form of dependency) has a significant negative association with the Quality of

Attachment factor (r = -.24, p = .02). Adding to the confusion, Rude and Burnham’s

Neediness (the unhealthy, pathological type of dependency), has the exact same significant

negative association with Quality of attachment (r =-.24, p =.02). It is difficult to

understand why both the healthy and unhealthy forms of dependency would be negatively

correlated with attachment quality. This might be instrument error, or some piece of the

Dependency construct might be relating in an underlying fashion to the attachment measure.

When all eight scores are subjected to a linear regression with the Global attachment

score, all fail to reach significance. The standard scoring system and the McGill scoring

system are slightly more powerful than the subscales of the Dependency factor, no doubt

because of the inclusion of the Self-Criticism factor. Although it is possible that a larger

sample size would drive some of these analyses into significance, it appears that the

relationship of self-critical and dependent tendencies with attachment is far less important

than the relationship between depression and attachment. The Self-Critical and Dependent

factors of the DEQ may be more valuable in identifying risk factors for postpartum

depression than in identifying risk factors for low or poor quality attachment.

97

Gestational Age and Attachment

Since previous research has suggested that attachment grows with gestational age, it

was surprising that gestational age was not associated with the level of attachment reported

by the participants. A common observation across studies has been that fetal movement is a

trigger for increased antenatal attachment, and all subjects in this sample had experienced

quickening (Mikhail et al., 1991; Reading et al., 1984). This may have rendered the analyses

useless. However, one narrative underscores the individual nature of antenatal bonding:

“…I must say that he wasn’t planned. Me and his father were not trying to get pregnant, but it happened so quickly my eyes didn’t have time to blink.

I didn’t bond with him until I was almost 5 months pregnant. At this time, that’s when the secret about me being pregnant was finally out of the bag to my family and everybody I hid it from…”

Another confounding issue with this research is that all participants had received at

least one sonogram, many of them three-dimensional, and had pictures of the fetus at

bedside. The impact upon antenatal attachment of viewing the fetus through sonogram has

been under investigation although findings have been inconclusive (Reading et al., 1984;

Righetti, Dell'Avanzo, Grigio, & Nicolini, 2005).

Exploring Fetal Object Representation

In addition to testing the hypotheses, a few other questions were asked. Joy Penticuff

highlighted the developmental resolution of ambivalence toward a new member of the family

that occurs over the course of pregnancy (Penticuff, 1982). It was supposed that this

ambivalence was intensified in mothers with higher obstetric risks. However, in all the

analyses of risk, no significant association was found between the Ambivalence dimension of

the ORI and risk. There was a significant association between Ambivalence in the mother

98

narrative and Ambivalence in the baby narrative, suggesting that these conflicting feelings

may be more a characteristic of the mother rather than of a particular mental representation.

In addition, Ambivalence was negatively correlated with the Global attachment score,

implying that this characteristic has implications for antenatal attachment.

Other analyses tested for relationships between the ORI dimensions, ethnicity and

age, with no significant differences found in the narratives. The ability to convey complex

information about mother or baby does not seem to be related to factors outside the process

of mental representation.

A final curiosity about the fetal narrative had to do with the theories behind internal

working models and mental representations. If these are activated during infancy and are

primarily associated with caregiver relationships (and later to romantic attachment figures),

perhaps there is a distinctly different model or representation a mother constructs of her

child. This model and representation may be focused on caregiving, instead of care

“receiving.” If so, multiparous women might have a certain facility with the mental

representation of their baby that nulliparous women, with no previous model or

representation of a baby, do not possess. This was not borne out statistically and, although

the sample size was adequate for the chi-square analysis, there were no significant

differences in the Conceptual Level of the fetal narratives according to parity.

99

Maternal Antenatal Attachment Scale

The positive correlation between age and the Quality of attachment factor was

moderately strong (r = .292, p = .005). It appears that older mothers may have more positive

thoughts about their babies than younger ones, although there is no difference in their level of

preoccupation with the fetus. It has also been stated that multiparous women spend less time

in “attachment mode” because of caregiving responsibilities for other children. However,

this was unsupported in the sample, as there were no differences in attachment scores

between first-time mothers and those with children at home.

THEORETICAL IMPLICATIONS

While this study did not find the proposed relationships between personality

characteristics, mental representation, and attachment, the limitations of the sample size warn

against premature conclusions. This work did, however, contribute to the ongoing dialogue

regarding the construct of antenatal attachment and its associations. In addition, it provided a

valuable, diverse sample of hospitalized women who enabled research to ask old questions in

a new context.

CLINICAL IMPLICATIONS

Even though the construct of antenatal attachment remains elusive, this research also

adds value to the growing investigation into the insidious link between depression and

attachment. Whether depressed mothers suffer from impaired attachment or a mother’s

inability to attach to a baby contributes to a vulnerability to depression remains to be seen.

100

These findings support all those before that point to the necessity of identifying, targeting,

and intervening where possible to enhance maternal-fetal attachment and treat perinatal

depression.

The idea that self-critical tendencies are a detractor of attachment as well as a strong

contributor to depressive symptomatology is not new, but this research has broadened its

application to the population of women with high-risk pregnancy. In fact, self-criticism may

be a salient contributor in this population in view of the tendency for women with high-risk

to look inward for a causal relationship between something they did or did not do and the

complications. The findings in this research, consistent with those of the Priel and Besser

team in Israel, suggest that pregnant women who are self-critical are vulnerable to depressive

feelings and may benefit from interventions that expose these tendencies. In addition, since

self-criticism also impacts antenatal attachment, interventions that enhance attachment to the

fetus may be indicated.

Although cognitive-behavioral and interpersonal approaches with postpartum

depression have been empirically studied (Dennis, 2004), only one reference was found that

suggests treating childbearing depression from an attachment theory framework (Whiffen &

Johnson, 2006). This case example illustrated how Emotionally Focused Marital Therapy, a

manualized psychotherapy based upon attachment theory, could be employed in treating

postpartum depression. Social support has been found to be protective against perinatal

depression (Priel et al., 2000a), so targeting depression from a “couples” standpoint would be

ideal for enhancing attachment and encouraging partner support. This could be even more

critical in women with obstetric risks. Hospitalization separates them from their partners,

101

increases the partner burden in terms of household, family, and financial responsibilities, and

sets in place a fertile environment for partner blame and discord. Progressive hospitals have

added group therapy to antepartum unit care for psychosocial support with equivocal results

(Dennis, 2004). Perhaps focusing on the marital dyad would be more effective in the

prevention of perinatal depression. Interventions that highlight emotional expression and

foster understanding of each spouse’s needs and childbearing fears could be operationalized

in group sessions, similar to childbirth classes, or in the hospital room privately.

LIMITATIONS AND FUTURE DIRECTIONS

The study shared two common limitations to research of this sort. Self-report

measures are often the only practical way to approach cross-sectional research. In the battery

of measures for this study, other than the ORI, the questionnaires were all forced choice

Likert-type instruments. Future research might include other forms of data gathering, such as

structured interviews or family reports. In addition, although the instruments utilized in this

study are considered to be reliable and valid, more research is needed to assess the extent to

which they genuinely evaluate these particular constructs of personality, mental

representation, and attachment.

A possible limitation for this work specifically has to do with the method of

administration of the ORI. Because this investigation was a small piece of a larger study

including a number of measures, it was decided to include the ORI in the questionnaire

packet. Although study personnel conscientiously explained to the participants to “take five

minutes and write a description of your mother and the baby you are carrying,” the packets

102

were left for completion and in some cases the narratives were either skipped (five of the 91

subjects did not complete either the mother or the baby narrative and an additional three did

not complete the mother narrative) or so short that some of the descriptive qualities were by

necessity scored as “missing.” Future studies of this sort might consider conducting the ORI

in more of an interview fashion. Initial remarks could be recorded and probing questions

asked if additional information is needed.

Rating the fetal narratives according to the standard scoring system was not possible,

as explained earlier, because the descriptives were inappropriate in application to a fetus

(Affectionate, Ambitious, Malevolent/Benevolent, Cold-Warm, Constructive Involvement,

Intellectual, Judgmental, Negative/Positive Ideal, Nurturant, Punitive, Successful, and

Strength). However, the narratives did often contain the themes Condon posits are found in

human attachment: the desire to know, the desire to be with, the desire to protect, and the

desire to prevent loss or separation. They also reflected the themes found in the earlier cited

research on antenatal fantasies: Appearance, psychological traits, gender, behavior,

normalization, deification, role relations, impact on parents, spiritual, and ambiguity

(Sorenson & Schuelke, 1999). An intriguing future exploration might involve the use of the

ORI with a specialized rating system for the fetus utilizing these previously noted themes.

Diverse samples are both desirable and problematic. Participants in this sample

covered a broad range of age, previous pregnancy experiences, cultural backgrounds,

educational levels, and socioeconomic factors. Some were from the Dallas Metroplex, a

sprawling urban environment, and others had spent their lives in small rural communities

103

well outside city life. They represent the diversity of the state of Texas fairly, however the

experience of obstetric risk is distinct from individual to individual.

The women who agreed to participate knew they were taking part in research

investigating emotions during hospitalization, so the sample may have been biased by this

knowledge. Even though all subjects were approached within 72 hours of hospitalization,

not all completed the instruments in a timely manner. Some completed quickly, others may

have taken several days. In addition, due to HIPAA regulations, it was not possible to gather

data about those who declined to participate in the research. An observation from other work

has been that those who do not participate may not do so because they are depressed. This

possibility may impair the generalizability of the findings.

Since risk was not found to have significance in these findings, a number of avenues

of investigation would be elucidating. One calls for evaluating the woman’s perspective of

the risk, in terms of both severity and the necessity of behavioral alterations. A second

approach would entail an examination of the coping resources and social support systems of

women who are hospitalized. These variables may moderate the additional stress of obstetric

risk and hospitalization. Hospitalization itself plays the part of a social support system—a

valuable look at this variable might include a population of women with complications who

are prescribed bed-rest at home. Thirdly, there has been some suggestion that depression

may be related to specific obstetric risks, such as preeclampsia (Kurki et al., 2000). A larger

sample size would permit an investigation of the impact of specific risk factors upon

attachment and depression.

104

Since no causal inferences can be made from studies like this one, longitudinal

research on women from this population would be of great value. There are many

unanswered questions concerning perinatal mental health and mother child relationships that

can only be addressed by research covering longer time periods.

Continuing the investigation into the association between attachment and depression

is vital. As observed in this research, attachment has a stronger relationship with depressive

symptoms than many other elements in the context of complicated pregnancy. In light of the

difficult decision in prenatal screening for depression of whether to increase sensitivity and

lose specificity, resulting in large numbers of false positive screenings, or decrease sensitivity

and gain specificity, risking missing depression entirely, perhaps attachment measures such

as the MAAS and personality measures such as the DEQ could supplement traditional

instruments, increasing sensitivity and specificity in the screening process. Obstetricians,

pediatricians, nurses, and social workers are in a place of advantage for intervention with

hospitalized pregnant women identified as being at risk for depression. Multidisciplinary

teams that include psychologists and psychotherapists would afford intervention at the

earliest point possible, before the baby is born.

CONCLUSION

Women who are hospitalized with high-risk pregnancy are admitted with a host of

individual needs and concerns. Some are trying desperately to hang on to a longed-for

pregnancy, some are anxious about how their family will fare in day-to-day life without

them, and others are content to stay in the care of professionals during an uncertain time.

105

They have idiosyncratic histories. Some women in this study had experienced successful,

uncomplicated pregnancies previously, while others had buried stillborns. Because Baylor

Hospital draws a diverse geographical population, women from rural farming communities

were in rooms next to women who had never been outside the city of Dallas. And in the way

of society, some patients had visitors every day and a room full of flowers while others slept

all day in darkened rooms. What they all had in common was one (or both) of two questions:

“Will my baby make it to viability? Will my baby be born OK?”

One goal of this research was to take a closer look at perinatal depression by way of

attachment. These findings agreed with other studies that have consistently pointed to the

relationship between attachment and depression. Also apparent from this work is just how

well antenatal attachment eludes theorists and clinicians alike. It was thought that exploring

this concept in the context of risk and uncertainty would contribute to the shared

understanding of what psychodynamic forces contribute to this primordial phenomenon of

mother-baby love. Attachment was slippery even in this perfect Bowlbian environment.

What did emerge clear and strong was that women report strong attachment to their fetuses

regardless of what gestational age they are, regardless of what type of mother they had

themselves, and regardless of the risk carrying this baby poses to their own life. Women who

are sad are not as sure of this attachment, but it is there, nonetheless. Women who are self-

critical may be afraid they cannot live up to the demands of mothering, but they are attached

too. These mothers just need a little help.

The continued exploration of antenatal attachment is a worthy venture, but the next

step is to take what is known and make application to intervention. The findings of this study

106

add in a small way to the growing body of knowledge that will help develop interventions

specific to impaired maternal attachment and perinatal mood disorders.

107

Figure 1 Levels of Mother Narrative Conceptual Level Across Low, Medium, and High Quality of Attachment Scores

3.002.001.00

MAAS Low, Medium, and High Quality of Attachment

30

20

10

0

ORI Mother

51Development

73

Cou

nt

Note: ORI = Object Relations Inventory 1 = Preoperational 3 = Concrete 5 = External Iconic 7 = Internal Iconic MAAS = Maternal Antenatal Attachment Scale Low = Lowest score through -.6 SD Medium = -.5 - .5 SD High = .5 through highest score

108

Figure 2 Levels of Mother Narrative Conceptual Level Across Low, Medium, and High Intensity of Attachment Scores

3.002.00

25

20

15

10

5

1.00

MA and High Intensity of Attachment

0

AS Low, Medium,

Cou

nt

75

31

ORI MotherDevelopment

ote:

5 = External Iconic 7 = Internal Iconic MAAS = Maternal Antenatal Attachment Scale Low = Lowest score through -.6 SD Medium = -.5 - .5 SD High = .5 through highest score

N ORI = Object Relations Inventory 1 = Preoperational 3 = Concrete

109

Figure 3 Quality of Attachment and Mother Narrative Conceptual Level

7531

ORI Mother Narrative Levels of Development

50

48

46

44

42

40

38

36

MA

AS

Qua

lity

of A

ttach

men

t

Note: MAAS = Maternal Antenatal Attachment Scale ORI = Object Relations Inventory 1 = Preoperational 3= Concrete 5 = External Iconic 7 = Internal Iconic

110

Figure 4 Intensity of Attachment and Mother Narrative Conceptual Level

7531

ORI Mother Narrative Levels of Development

40

35

30

25

20

15

MA

AS

Inte

nsity

of A

ttach

men

t

Note: MAAS = Maternal Antenatal Attachment Scale ORI = Object Relations Inventory 1 = Preoperational 3= Concrete 5 = External Iconic 7 = Internal Iconic

111

Figure 5 Global Attachment and Mother Narrative Conceptual Level

7531

ORI Mother Narrative Levels of Development

100

90

80

70

60

MA

AS

Glo

bal A

ttach

men

t Sco

re

Note: MAAS = Maternal Antenatal Attachment Scale ORI = Object Relations Inventory 1 = Preoperational 3= Concrete 5 = External Iconic 7 = Internal Iconic

112

Figure 6 Distribution of Levels of ORI Narrative Conceptual Level

7531

ORI Baby Narrative Levels of Development

30

25

20

15

10

5

0

Cou

nt

75

31

ORI Mother NarrativeDevelopment

Note: ORI = Object Relations Inventory 1 = Preoperational 3 = Concrete 5 = External Iconic 7 = Internal Iconic

113

Figure 7 Attachment Style Based on Below and Above Means of MAAS Quality and Intensity Factors

Note: N = 91

QUALITY OF ATTACHMENT

(Positive)

PRE-OCCU-

PATION (Low)

PRE-

PoAtpre

QS

am

Condon, J.T. (1993).questionnaire instrum

18.7 % (17)

Quadrant 2: sitive Quality of

tachment but low occupation due todistraction or Avoidance

QUALITY OF ATTACHMENT (Ambivalent or

Detached)

27.5

QuadUninv

bivalenwit

preocc

QAnx

p

The assessment of antenatal emoent. British Journal of Medical

114

33% (30)

uadrant 1: trong/Healthy Attachment

OCCU-PATION (High)

20.9% (19)

uadrant 4: ious, ambivalent or affectless reoccupation

% (25)

rant 3: olved or tly involved h low upation

tional attachment: Development of a Psychology, 66, pp. 167-183.

Figure 8 Distributions of ORI Conceptual Levels of Mother Narrative Across DEQ Self- Criticism Scores

21

Level of Development of Mother Narrative

50

40

30

20

10

0

Cou

nt

21

SC Below and Abovethe Mean

Note: DEQ = Depressive Experiences Questionnaire ORI = Object Relations Inventory 1 = Preoperational/Concrete 2 = External/Internal Iconic

115

Figure 9 Distributions of ORI Conceptual Levels of Mother Narrative Across DEQ Dependency Scores

21

Level of Development of Mother Narrative

50

40

30

20

10

0

C

1

Depend Below andAbove Mean

2

ount

Note: DEQ = Depressive Experiences Questionnaire ORI = Object Relations Inventory 1 = Preoperational/Concrete 2 = External/Internal Iconic

116

Figure 10 Type of Risk and MAAS Global Attachment Scores

BothFetalMaternal

Maternal, Fetal, or Combined Obstetric Risk

100

90

80

70

60

MA

AS

Glo

bal A

ttach

men

t Sco

re

Note: MAAS = Maternal Antenatal Attachment Scale

117

Figure 11 Type of Risk and MAAS Intensity of Attachment

3.002.001.00

Attachment Intensity Level

25

20

15

10

5

0

Cou

nt

BothFetalMaternal

Maternal or Fetal

Note: MAAS = Maternal Antenatal Attachment Scale

118

Table 1 Demographic Characteristics of Total Sample (n=90)

Variable

N

M

SD

Range

Age (years)

91

27.01

6.44

17-44

Children (natural children in household)

87 1.02 1.45 0-6

Comparison of Sample Population with Dallas County Ethnicity Proportions Variable

N

%

Dallas County

% Ethnicity

African American

30 33.0 20.3

Hispanic

10 11.0 35.6

Caucasian

49 53.8 49.4

Asian

2 2.2 4.3

(Demographic Table continues)

119

Demographic Table (continued) Variable

N

%

Marital Status

Single

29 31.9

Married

49 53.8

Cohabiting

9 9.9

Separated

3 3.3

Undetermined

1 1.1

Education 9-12 Years

10 11.0

HS or GED

23 25.3

Some College

30 33.0

College Degree

24 26.4

Undetermined

4 4.4

Annual Household Income Under $12,000

5 5.6

$12,000-25,000

22 24.2

$26,000-40,000

15 16.5

$41,000-65,000

15 16.5

Over $65,000

26 28.6

Undetermined 8 8.8

(Table continues)

120

(Demographic Table continued) Variable

N

%

Biological Children at Home

None 41 45.1

One 30 33.0

Two 6 6.6

Three 4 4.4

Four 3 3.3

Five 1 1.1

Six 3 3.3

Undetermined 3 3.4

Note: N = 91

121

Table 2

Pregnancy Characteristics of Sample

Variable

N

%

Total Prior Pregnancies

0

29 31.9

1

22 24.2

2

20 22.0

3

10 11.0

4 or more

9 9.8

Undetermined

1 1.1

Previous Stillborn or Neonatal Demise

4 4.5

Previous Miscarriage

24 27.3

Previous Pregnancy Termination 8 9.1

Onset of Complications

First Trimester 10 11.0

Second Trimester 34 37.4

Third Trimester 42 46.2

Complications with Previous Pregnancies 34 37.4

122

Table 3 Psychiatric Characteristics of Sample

Variable

N

%

Previous Psychiatric History

Depression 6 6.6

Anxiety 6 6.6

Comorbid Depression and Anxiety 3 3.3

Bipolar Disorder 1 1.1

Undetermined 6 6.6

Positive Screening for Depression at Admission

CES-D (score > 16) 33 36.3

EPDS (score > 11) 38 41.8

Positive Diagnosis on SCID

Mood Disorder 0 0

Anxiety Disorder 5 5.5

Comorbid Mood and Anxiety Disorders 2 2.2

Family History of Psychiatric Illness 16 17.6

Note: EPDS = Edinburgh Postpartum Depression Scale CES-D = Center for Epidemiological Studies-Depression

SCID = Structured Clinical Interview for the Diagnosis of DSM-IV Axis One Disorders

123

Table 4

Means and Standard Deviations of Measures

Measure

N

M

SD

Range

Depressive Symptoms (Screening Measures) EPDS (Depression suggested at > 11)

91

9.46

5.54

0-22

CES-D (Depression suggested at > 16)

75 15.88 10.37 0-37

Personality(DEQ) Dependent Characteristics

91

-.53

.90

-2.60-1.21

Self-Critical Characteristics

91 -.93 1.01 -2.92-2.25

Antenatal Attachment (MAAS) Global Attachment Score

91

81.49

7.13

61-95

Quality of Attachment Factor

91 46.01 3.48 33-50

Intensity of Attachment Factor

89 30.71 4.88 17-40

Object Representation of Mother (ORI) Benevolent Qualities

81

4.11

1.54

.63-7.88

Punitive Nature

81 1.49 1.42 .33-6.33

Ambitious Characteristics

39 3.53 1.69 .50-7.00

Ambivalent Feelings about Mother

83 1.83 1.3 1-5

Length of Narrative

83 2.41 1.54 1-7

Conceptual Level of Narrative

83 5.17 1.22 1-7

(Table continues)

124

125

Means and Standard Deviations of Measures (continued) Measure

N

M

SD

Range

Object Representation of Fetus (ORI) Length of Narrative

85

2.2

1.64

1-7

Ambivalent Feelings about Baby

85 1.42 1.03 1-5

Conceptual Level of Narrative

85 4.46 2.15 1-7

Severity of Risk Hobel Risk Assessment, Revised

91

18.35

9.62

5-45

Note: EPDS = Edinburgh Postpartum Depression Scale

CES-D = Center for Epidemiological Studies-Depression DEQ = Depressive Experiences Questionnaire MAAS = Maternal Antenatal Attachment Scale ORI = Object Relations Inventory

Table 5 Means and Standard Deviations on Dimensions of the Object Relations Inventory Mother Narrative for Global Attachment Above and Below the Mean

Mother Narrative

Benevolent

Punitive

Ambitious

Length

Ambivalence

Conceptual

Level MAAS Global Attachment Score (M = 81.5)

M SD

M SD

M

SD M

SD M

SD M

SD

Below the Mean 4.38

2.11 1.81

1.65

3.43

1.70 2.79

1.85 2.43

1.79 5.57

1.22

Above the Mean 4.27

1.20 1.72

1.61

3.58

1.72 2.28

1.28 1.88

1.24 5.08

.91

Note: N = 83 MAAS = Maternal Antenatal Attachment Scale

126

Table 6 Means and Standard Deviations on Dimensions of the Object Relations Inventory Mother Narrative for Global Attachment by Standard Deviation

Mother Narrative

Benevolent

Punitive

Ambitious

Length

Ambivalence

Conceptual

Level MAAS Global Attachment Score (M = 81.5)

M SD

M SD M

SD M

SD M

SD M

SD

Low (Lowest through -.99 SD (SD = 7.12))

3.93 2.26 1.05

.99 4.07

1.88 2.00

1.41 2.29

1.89 5.29

1.38

Average -1 SD through 1 SD

4.34 1.50 2.08 1.77 3.44 1.73 2.80 1.61 2.20 1.47 5.48.872

High 1.1 SD through Highest

4.57 1.03 1.28 1.23 3.29 1.47 1.71 .76 1.43 .787 4.43 .98

Note: N = 83 MAAS = Maternal Antenatal Attachment Scale

127

Table 7 95% Confidence Intervals of Pairwise Differences in Mean Changes of Attachment Quality (MAAS) by Conceptual Level of ORI Mother Narrative

M

SD

Pre- operational

Concrete

External Iconic

Pre-operational 47.00

2.83 Concrete 44.67 4.08 -41.93 to 37.26

External Iconic 46.16 3.37 -46.41 to 44.72

-4.76 to 7.73

Internal Iconic 46.18 2.74 -45.46 to 43.82

-4.91 to 7.93 -2.21 to 2.26

Note: N = 83 MAAS = Maternal AntenatalAttachment Scale ORI = Object Relations Inventory

128

Table 8 95% Confidence Intervals of Pairwise Differences in Mean Changes of Attachment Intensity (MAAS) by Conceptual Level of ORI Mother Narrative

M

SD

Pre- operational

Concrete

External Iconic

Pre-operational 30.67

4.91 Concrete 30.17 6.74 -5.33 to 2.80

External Iconic 31.32 4.97 -4.46 to .82

.87 to 2.83

Internal Iconic 29.06 4.11 -6.44 to 1.14

-1.10 to 2.94 -1.97 to 1.22

Note: N = 81 MAAS = Maternal AntenatalAttachment Scale ORI = Object Relations Inventory

129

130

Table 9 Frequency Distribution of Conceptual Levels of Mother and Baby Narratives (ORI)

Mother Narrative

Baby Narrative

N

Percent

Cumulative

Percent

N

Percent

Cumulative

Percent

Sensorimotor 2

2.4 2.4 18 21.2 21.2 Concrete 6 7.2 9.6 9 10.6 31.8 External Iconic 58 69.9 79.5 36 42.4 74.1 Internal Iconic 17 20.5 100.0 22 25.9 100.0 Total

83 100.0 85 100.0

Note: ORI = Object Relations Inventory

131

Table 10 Spearman’s rho Correlations for Conceptual Level and Attachment

ORI

Conceptual Conceptual

Level Mother

MAAS Quality

MAAS

Intensity

Conceptual Level of Mother

X

.023 N = 83

-.210 N= 81

Quality of Attachment Factor

X

X

.379** N = 89

Intensity of Attachment Factor

X X X

Note: MAAS = Maternal Antenatal Attachment Scale

ORI = Object Relations Inventory ** p < .01

132

Table 11 Two-Way Contingency Table of Levels of Object Representation of Mother and Quality of Attachment Above and Below the Mean ORI Object

Representation

Sensorimotor

Concrete

External Internal Iconic

% (N) % (N) Pearson χ² = .855, p = .465

MAAS Quality of Attachment Factor (M = 46.01)

Below the Mean

6.0 (5) 41.0 (34)

Above the Mean

3.6 (3) 49.4 (41)

Note: N = 83

MAAS = Maternal Antenatal Attachment Scale ORI = Object Relations Inventory

133

Table 12 Two-Way Contingency Table of Levels of Object Representation of Mother and Quality of Attachment by Standard Deviation

ORI Object Representation

Sensorimotor

Concrete

External Internal Iconic

% (N) % (N) Pearson χ² = 2.732, p = .255

MAAS Quality of Attachment Factor (M = 46.01)

Low (.6 SD Below the Mean)

2.4 (2) 18.1 (15)

Average (.5 SD Below the Mean to .5 SD) Above the Mean

4.8 (4) 48.2 (40)

High (.6 SD Above the Mean)

2.4 (2) 24.1 (20)

Note: N = 83

MAAS = Maternal Antenatal Attachment Scale ORI = Object Relations Inventory

134

Table 13 Two-Way Contingency Table of Levels of Object Representation of Mother and Intensity of Attachment Above and Below the Mean ORI Object

Representation

Sensorimotor

Concrete

External Internal Iconic

% (N) % (N) Pearson χ² = .173, p = .727

MAAS Intensity of Attachment Factor (M = 30.71)

Below the Mean

3.7 (3) 40.7 (33)

Above the Mean

6.2 (5) 49.4 (40)

Note: N = 81

MAAS = Maternal Antenatal Attachment Scale ORI = Object Relations Inventory

135

Table 14 Two-Way Contingency Table of Levels of Object Representation of Mother and Intensity of Attachment by Standard Deviation

ORI Object Representation

Sensorimotor

Concrete

External Internal Iconic

% (N) % (N) Pearson χ² = 2.04, p = .361

MAAS Intensity of Attachment Factor (M = 30.71)

Low (.6 SD Below the Mean)

2.5 (2) 32.1 (26)

Average (.5 SD Below the Mean to .5 SD)

1.2 (1) 24.7 (20)

High (.6 SD Above the Mean)

6.2 (8) 33.3 (27)

Note: N = 81

MAAS = Maternal Antenatal Attachment Scale ORI = Object Relations Inventory

Table 15 Means and Standard Deviations on Dimensions of the Object Relations Inventory for Global Attachment Above and Below the Mean Baby Narrative

Length

Ambivalence

Conceptual Level MAAS Global Attachment Score (M = 81.5)

M

SD

M SD

M SD

Below the Mean

2.17

1.73

1.83

1.42 4.44

2.12

Above the Mean

2.22

1.59

1.12

.39 4.47

2.19

Note: N = 83

MAAS = Maternal Antenatal Attachment Scale

136

Table 16 Means and Standard Deviations on Dimensions of the ORI for Global Attachment by Standard Deviation Baby Narrative

Length

Ambivalence

Conceptual Level MAAS Global Attachment Score (M = 81.5)

M

SD

M

SD

M SD

Low (.6 SD Below the Mean)

2.05 1.76 2.14 1.67 4.18 2.11

Average (.5 SD Below the Mean to .5 SD)

2.22 1.62 1.22 .540 4.50 2.16

High (.6 SD Above the Mean)

2.30 1.61 1.11 .424 4.63 2.22

Note: N = 83

MAAS = Maternal Antenatal Attachment Scale

137

138

Table 17 Spearman’s rho Correlations for Object Representations of Mother and Baby Narratives

ORI Dimensions

Mother

Ambivalence

Mother Length

Mother

Conceptual Level

Baby

Ambivalence

Baby Length

Baby

Conceptual Conceptual

Level

Ambivalent Feelings about Mother

X .403***N = 82

.102 N = 82

.458*** N = 81

.401** N = 81

.065 N = 81

Length of Narrative about Mother

X

X .171N = 83

.184 N = 82

.720*** N = 82

.270** N = 82

Conceptual Level of Mother

X X X .310**N = 82

.307** N = 83

.068 N = 82

Ambivalent Feelings about Baby

X X X X .355**N = 85

-.170 N = 85

Length of Narrative about Baby

X X X X X .127N = 82

Conceptual Level of Baby

X X X X X X

Note: ORI = Object Relations Inventory * p < .05; ** p < .01; *** p < .001

139

Table 18 Two-Way Contingency Table of ORI Conceptual Level of Mother Narrative by Baby Narrative

Baby Narrative

Mother Narrative

Sensorimotor Concrete

External/ Internal Iconic

% (N) % (N) Pearson χ² (1, 82) = .206 p = .70

Sensorimotor/ Concrete

3.7 (3) 26.8 (22)

External/Internal Iconic

6.1 (5) 63.4 (52)

Note: N = 83 ORI = Object Relations Inventory

Table 19

Pearson Product- Moment Correlations of Dependency, Self-Criticism, and Maternal Antenatal Attachment

DEQ

Dependent

DEQ

Self-Critical

MAAS Quality

MAAS

Intensity

MAAS Global

Personality(DEQ) Dependent Characteristics

X

.015n = 91

-.021 n = 91

.0777 n = 89

.037 n = 91

Self-Critical Characteristics

X

X -.366***n = 91

-.025 n = 89

-.198 n = 91

Antenatal Attachment (MAAS) Quality of Attachment Factor

X X X .410***n = 89

.777*** n = 91

Intensity of Attachment Factor

X X X X .887***n = 89

Global Attachment Score

X X X X X

Note: MAAS = Maternal Antenatal Attachment Scale DEQ = Depressive Experiences Questionnaire

140

Table 20

Two-Way Contingency Table of Self-Criticism (Low, Average, and High) and Antenatal Attachment Style DEQ Self-Critical Factor Antenatal Attachment Style (MAAS)

Low

< -1 SD

Average

> -1 to < 1 SD

High

> 1 SD

N N N Pearson x² (6, 91) = 5.714, p = .456

1) High Quality, High Intensity (Strong, secure)

6.6 (6)

22.0 (20)

4.4 (4)

2) High Quality, Low Intensity (Anxious Avoidant)

4.4 (4)

13.2 (12)

1.1 (1)

3) Low Quality, Low Intensity (Withdrawn)

3.3 (3)

17.6 (16)

6.6 (6)

4) Low Quality, High Intensity (Anxious Ambivalent)

1.1 (1)

14.3 (13)

5.5 (5)

Note: N = 91

MAAS = Maternal Antenatal Attachment Scale DEQ = Depressive Experiences Questionnaire, Self-Criticism Factor, M = -.925, SD = 1.01

141

Table 21

Two-Way Contingency Table of Self-Criticism (Above the Mean and Below the Mean) and Antenatal Attachment Style

DEQ Self-Critical Factor

Antenatal Attachment Style (MAAS)

Below the Mean

Above the Mean

N N Pearson x² (3, 91) = 8.932, p = .03 1) High Quality, High Intensity (Strong, secure)

20.9 (19)

12.1 (11)

2) High Quality, Low Intensity (Anxious Avoidant)

15.4 (14)

3.3 (3)

3) Low Quality, Low Intensity (Withdrawn)

13.2 (12)

14.3 (13)

4) Low Quality, High Intensity (Anxious Ambivalent)

7.7 (7)

13.2 (12)

Note: N = 91

MAAS = Maternal Antenatal Attachment Scale DEQ = Depressive Experiences Questionnaire, Self-Criticism Factor, M = -.925, SD = 1.01

142

Table 22 Two-Way Contingency Table of Dependency (Low, Average, and High) and Antenatal Attachment Style

DEQ Dependent Factor

Antenatal Attachment Style (MAAS)

Low

< -1 SD

Average

> -1 to < 1 SD

High

> 1 SD

N N N Pearson x² (6, 91) = 10.412, p = .108

1) High Quality, High Intensity (Strong, secure)

19.8 (18)

1.1 (1)

12.1 (11)

2) High Quality, Low Intensity (Anxious Avoidant)

8.8 (8)

2.2 (2)

7.7 (7)

3) Low Quality, Low Intensity (Withdrawn)

16.5 (15)

0

11.0 (10)

4) Low Quality, High Intensity (Anxious Ambivalent)

6.6 (6)

0

14.3 (13)

Note: N = 91

MAAS = Maternal Antenatal Attachment Scale DEQ = Depressive Experiences Questionnaire, Dependency Factor, M = -.53, SD = .90

143

Table 23

Two-Way Contingency Table of Dependency (Above the Mean and Below the Mean) and Antenatal Attachment Style

DEQ Dependent Factor

Antenatal Attachment Style (MAAS)

Below the Mean

Above the Mean

N N Pearson x² (3, 91) = 4.55, p = .207 1) High Quality, High Intensity (Strong, secure)

17.6 (16)

15.4 (14)

2) High Quality, Low Intensity (Anxious Avoidant)

8.8 (8)

9.9 (9)

3) Low Quality, Low Intensity (Withdrawn)

15.4 (14)

12.1 (11)

4) Low Quality, High Intensity (Anxious Ambivalent)

5.5 (5)

15.4 (14)

Note: N = 91

MAAS = Maternal Antenatal Attachment Scale DEQ = Depressive Experiences Questionnaire, Dependency Factor, M = -.53, SD = .90

144

Table 24

Two-Way Contingency Table of Self-Criticism (Low, Average, and High) and Conceptual Level of Mother Narrative

DEQ Self-Critical Factor

ORI Mother Narrative Conceptual Level

Low

< -1 SD

Average

> -1 to < 1 SD

High

> 1 SD

% (N) % (N) % (N) Pearson x² (6, 83) = 4.763, p = .575

Sensorimotor

1.2 (1) 1.2 (1) 0

Concrete

1.2 (1) 4.8 (4) 1.2 (1)

External Iconic

9.6 (8) 50.6 (42) 9.6 (8)

Internal Iconic

3.6 (3) 10.8 (9) 6.0 (5)

Note: N = 83

ORI = Object Relations Inventory DEQ = Depressive Experiences Questionnaire, Self-Criticism Factor, M = -.925, SD = 1.01

145

Table 25

Two-Way Contingency Table of Dependency (Low, Average, and High) and Conceptual Level of Mother Narrative

DEQ Dependent Factor

ORI Mother Narrative Conceptual Level

Low

< -1 SD

Average

> -1 to < 1 SD

High

> 1 SD

N N N Pearson x² (6, 83) = 7.47, p = .28

Sensorimotor

1.2 (1) 0 1.2 (1)

Concrete

6.0 (5) 0 1.2 (1)

External Iconic

33.7 (28) 1.2 (1) 34.9 (29)

Internal Iconic

7.2 (6) 2.4 (2) 10.8 (9)

Note: N = 83

ORI = Object Relations Inventory DEQ = Depressive Experiences Questionnaire, Dependency Factor, M = -.53, SD = .90

146

Table 26

Two-Way Contingency Table of Object Representation and Self-Critical Characteristics (Below the Mean and Above the Mean)

DEQ Self-Critical Factor

ORI Mother Narrative Conceptual Level

Below the Mean

Above the Mean

% (N) % (N) Pearson x² (1, 83) = 1.50, p = .272 Sensorimotor/ Concrete

3.6 (3)

6.0 (5)

External/Internal Iconic

54.2 (45)

36.1 (30)

Note: N = 83

ORI = Object Relations Inventory DEQ = Depressive Experiences Questionnaire, Self-Criticism Factor, M = -.925, SD = 1.01

147

148

Table 27

Two-Way Contingency Table of Object Representation and Dependent Characteristics (Below the Mean and Above the Mean)

DEQ Dependent Factor

ORI Mother Narrative Conceptual Level

Below the Mean

Above the Mean

% (N) % (N) Pearson x² (1, 83) = 1.32, p = .284 Sensorimotor/ Concrete

6.0 (5)

3.6 (3)

External/Internal Iconic

37.3 (31)

53.0 (44)

Note: N = 83

ORI = Object Relations Inventory DEQ = Depressive Experiences Questionnaire, Dependency Factor, M = -.53, SD = .90

149

Table 28 Hobel Risk Assessment Factors Identified as Fetal Previous fetal exchange transfusion for Rh Prevous premature infant Previous neonatal death Fetal anomalies Incompetent cervix Polyhydramnios Multiple pregnancy Viral disease Rh sensitization only Vaginal spotting Alcohol (moderate) Premature rupture of membrane (PROM)* Primary dysfunctional labor (PTL)*

* Items added as revision of scale

150

Table 29 Hobel Risk Assessment Factors Identified as Maternal Moderate to severe toxemia

Chronic Hypertension

Moderate to severe renal disease

Severe heart disease, Class II-IV

History of eclampsia

History of pyelitis

Class I heart disease

Mild toxemia

Acute pyelonephritis

History of cystitis

Acute cystitis

History of toxemia

Diabetes > Class A-II

Previous endocrine ablation

Thyroid disease

Prediabetes (A-I)

Family history of diabetes

Previous stillbirth

(Table continues)

151

(Maternal Risk Items continued) Post-term > 42 weeks

Previous cesarean section

Habitual abortion

Infant > 10 pounds

Multiparity > 5

Epilepsy

Uterine malformation

Abnormal fetal position

Small pelvis

Abnormal cervical cytology

Sickle cell disease

Age > 35 or < 15

Positive serology

Severe anemia (< 9 Gm. Hgb)

Excessive use of drugs

History of TB or PPD > 10 mm.

Weight < 100 or > 200 pounds

Pulmonary disease

Flu syndrome (severe)

(Table continues)

152

(Maternal Risk Items continued) Mild anemia (9-10.9 Gm. Hgb)

Smoking > 1 pack/day

Emotional problem

Placenta previa*

Abruptio placentae*

* Items added for revision of scale

153

Table 30

Means and Standard Deviations of MAAS Global Antenatal Attachment Scores Across Three

Types of Risk

M

SD

Fetal Risk

82.45

6.22

Maternal Risk 81.23 8.635 Fetal and Maternal Risk

80.67 6.97

Note: N = 91 MAAS = Maternal Antenatal Attachment Score

154

Table 31

Means and Standard Deviations of MAAS Global Antenatal Attachment Scores Across Two

Types of Risk

M

SD

Maternal Risk 81.23 8.635 Fetal and Fetal/Maternal Risk

81.58 6.64

Note: N = 91 MAAS = Maternal Antenatal Attachment Score

155

Table 32 95% Confidence Intervals of Pairwise Differences in Mean Changes of MAAS Attachment Intensity by Type of Risk

M

SD

Maternal

Fetal Maternal 30.52 5.45 Fetal 31.23 5.26 -3.12 to 4.54 Combined 30.39 4.31 -3.59 to 3.33 -3.76 to 2.08 Note: N = 89

MAAS = Maternal Antenatal Attachment Scale

156

Table 33

Two-Way Contingency Table of Three Risk Types and Antenatal Attachment (MAAS)

Maternal

Risk

Fetal Risk

Fetal/Maternal

Risk

% (N) % (N) % (N) Quality of Attachment Factor N = 91

Pearson x² (1, 91) = .39, p = .823

Above the mean score (46)

11.0 (10) 29.7 (27) 5.5 (5)

Below the mean score (46)

14.3 (13) 35.2 (32) 4.4 (4)

Intensity of Attachment Factor N = 89

Pearson x² (1, 89) = 1.36, p = .506

Above the mean score (31)

9.0 (8) 31.5 (28) 4.5 (4)

Below the mean score (31)

16.9 (15) 32.6 (29) 5.6 (5)

Global Attachment Score N = 89

Pearson x² (1, 89) = 2.245, p = .325

Above the mean score (81)

7.7 (7) 29.7 (27) 5.5 (5)

Below the mean score (81)

17.6 (16) 35.2 (32) 4.4 (4)

Note: MAAS = Maternal Antenatal Attachment Scale

Risk factors of revised Hobel assessment were categorized by the maternal-fetal medicine specialist, John Rosnes, M.D.

157

Table 34

Two-Way Contingency Table of Two Risk Types and Maternal Antenatal Attachment

Maternal

Risk

Fetal/Combined

Risk

Antenatal Attachment (MAAS)

% (n) % (n)

Quality of Attachment Factor N = 91

Pearson x² (1, 91) = 2.39,

p = .121 Above the mean score (46)

16.5 (15) 37.4 (34)

Below the mean score (46)

7.7 (7) 38.5 (35)

Intensity of Attachment Factor N = 89

Pearson x² (1, 89) = .048,

p = .826 Above the mean score (31)

13.5 (12) 34.8 (31)

Below the mean score (31)

10.1 (9) 34.8 (31)

Global Attachment Score N = 89

Pearson x² (1, 89) = .045,

p = .832 Above the mean score (81)

14.3 (13) 42.9 (39)

Below the mean score (81)

9.9 (9) 33.0 (30)

Note: MAAS = Maternal Antenatal Attachment Scale

Risk factors of revised Hobel assessment were categorized by the maternal-fetal medicine specialist, John Rosnes, M.D.

158

Table 35

Pearson Product-Moment Correlations for Severity of Risk and Maternal Antenatal Attachment

Hobel Risk Score, Revised

(Risk Severity)

MAAS Quality of Attachment Factor

r = -.175 p = .098

MAAS Intensity of Attachment Factor

r = -.101 p = .347

MAAS Global Attachment Score

r = -.146 p = .167

Note: N = 89

MAAS = Maternal Antenatal Attachment Scale

159

Table 36 95% Confidence Intervals of Pairwise Differences in Mean Changes of MAAS Attachment Intensity by Level of Risk

M

SD

Low

Medium

Low 31.91 4.93 Medium 30.11 4.83 -4.81 to 1.20 High 31.44 4.95 -5.84 to 4.90 -3.62 to 6.29

Note: N = 89

MAAS = Maternal Antenatal Attachment Scale

160

Table 37

Pearson Product-Moment Correlations for Gestational Age and Antenatal Attachment Antenatal Attachment (MAAS)

Gestational Age of Fetus(at Hospital Admission)

Quality of Attachment Factor

r = .080 p = .45

Intensity of Attachment Factor

r =.157 p = .142

Global Attachment Score

r = .135 p = .203

Note: N = 91 Gestational age of fetus in weeks as recorded at hospital admission MAAS = Maternal Antenatal Attachment Scale

Table 38

Pearson Product-Moment Correlations for Depressive Symptoms, Attachment, and Risk

Domain and Measure

Dependent

n = 91

Self-

Critical

n = 91

EPDS

n = 91

CES-D

n =75

MAAS Quality

n = 91

MAAS

Intensity

n = 89

MAAS Global

n = 91

Hobel Risk

n = 91

Personality (DEQ)

Dependent Characteristics

X

.015 .391*** .349*** -.021 .077 .037 -.125

Self-Critical Characteristics

X X .432*** .387*** -.366*** -.025 -.198 .121

Depressive Symptoms EPDS

X X X .812*** -.451*** -.035 -.247* .172

CES-D X X X X -.348** .110 -.095 .054

Attachment (MAAS) Quality of Attachment Factor

X X X X X .410*** .777*** -.138

Intensity of Attachment Factor

X X X X X X .887*** -.051

Global Attachment Score X X X X X X X -.090

Risk Hobel Risk Assessment, Revised

X X X X X X X X

Note: DEQ = Depressive Experiences Questionnaire; EPDS = Edinburgh Postpartum Depression Scale;

CES-D = Center for Epidemiology Studies-Depression; MAAS = Maternal Antenatal Attachment Scale * p < .05; ** p < .01; *** p < .001

161

Table 39 Correlations Between Major Demographic Variables, Depressive Symptoms (EPDS), and Antenatal Attachment (MAAS)

Age

Prior Preg

Gest Age

Children

EPDS

Risk

Quality

Intensity

Age

X

.293**

-.137

.152

-.108

.292**

.292**

-.016

Prior pregnancies

X

X

.075

.701***

.148

.431***

.028

.009

Gestational age at interview (Weeks)

X

X

X

.112

-.115

-.119

.080

.157

Children at home

X

X

X

X

.089

.218*

-.036

-.143

Depressive symptoms (EPDS)

X

X

X

X

X

.172

-.451**

-.035

Severity of Risk (Hobel)

X

X

X

X

X

X

-.138

-.051

Quality of Attachment Factor (MAAS)

X

X

X

X

X

X

X

.410***

Intensity of Attachment Factor (MAAS)

X

X

X

X

X

X

X

X

Note: MAAS = Maternal Antenatal Attachment Scale EPDS = Edinburgh Postpartum Depression Scale

* p < .05;** p < .01; *** p < .001

162

163

Table 40 95% Confidence Intervals of Pairwise Differences in Means of EPDS (Depressive Symptoms) Depressive Symptoms

HighQuality

High Intensity (Strong Secure)

High Quality

Low Intensity

(Avoidant)

Low Quality

Low Intensity

(Withdrawn)

M SD 1) High Quality, High Intensity (Strong, secure)

7.13

5.41

2) High Quality, Low Intensity (Anxious Avoidant)

6.53

4.53

-4.74 to 3.53

3) Low Quality, Low Intensity (Withdrawn)

12.40

4.14

1.74 to 8.80*

1.98 to 9.76*

4) Low Quality, High Intensity (Anxious Ambivalent)

11.89

5.47

.31 to 9.21*

.63 to 10.10*

-4.72 to 3.71

Note: EPDS = Edinburgh Postpartum Depression Scale MAAS = Maternal Antenatal Attachment Scale

An asterisk indicates tht the 95% confidence interval does not contain zero, and therefore the difference in means is significant at the .95 significance using Dunnett’s C procedure.

164

Table 41 Chi-Square Comparison of EPDS Depressive Symptomatology and MAAS Antenatal Attachment Style

EPDS Below Threshold

EPDS

Above Threshold

Antenatal Attachment Style % (N) % (N) 1) High Quality, High Intensity (Strong, secure)

26.4 (24)

6.6 (6)

χ² = 21.339, p = .000

2) High Quality, Low Intensity (Anxious Avoidant)

15.4 (14)

3.3 (3)

3) Low Quality, Low Intensity (Withdrawn)

7.7 (7)

19.8 (18)

4) Low Quality, High Intensity (Anxious Ambivalent)

8.8 (8)

12.1 (11)

Note: EPDS = Edinburgh Postpartum Depression Scale (Threshold for screening > 11) MAAS = Maternal Antenatal Attachment Scale

165

Table 42 Sample Means and Standard Deviations of Standard and Three Alternate Versions of Scoring of the Depressive Experiences Questionnaire

M

SD

Standard Dependency

-.53

.90

Standard Self-Criticism -.93 1.01

Blatt Revised Dependency 37.31 9.36

Blatt Relatedness 36.43 7.95

McGill Dependency 130.37 18.14

McGill Self-Criticism 101.25 19.41

Rude & Burnham Neediness -.31 .817

Rude & Burnham Connectedness -.58 .941

Note: N = 91 (Blatt et al., 1995; Santor, Zuroff, Mongrain, & Fielding, 1997b; Rude et al., 1995)

Table 43 Sample Intercorrelations of Four Scoring Methods of the Depressive Experiences Questionnaire

Standard

Blatt Revision

McGill Revision

Rude

& Burnham Revision

Depend SelfC Depend Relate Depend SelfC Need Connect

Standard Dependency

X

.015

.800***

.838***

.974***

-.028

.701***

.825***

Standard Self-Criticism X

X .361** .258* -.002 .976*** .440*** .193

Blatt Revised Dependency X X X .658*** .824*** .333** .870*** .593***

Blatt Relatedness X X X X .793*** .228* .625*** .829***

McGill Dependency X X X X X -.052 .740*** .750***

McGill Self-Criticism X X X X X X .387*** .156

Rude & Burnham Neediness X X X X X X X .377***

Rude & Burnham Connectedness X X X X X X X X

Note: N = 91; *p < .05; **p < .01; ***p < .000

166

Table 44

Pearson Product-Moment Correlations of DEQ Dependency, DEQ Self-Criticism, and MAAS Antenatal Attachment Using the

McGill Scoring Method

McGill

Dependent

McGill

Self-Critical

MAAS Quality

MAAS

Intensity

MAAS Global

Personality(DEQ) Dependent Characteristics

X

-.052

N = 91

-.060

N = 91

.057

N = 89

.004

N = 91 Self-Critical Characteristics

X

X

-.339** N = 91

-.049

N = 89

-.201

N = 91 Note: N = 91

MAAS = Maternal Antenatal Attachment Scale McGill = Revised Scoring of the Depressive Experiences Questionnaire (Santor et al., 1997b) **p < .01; ***p < .000

167

Table 45

Pearson Product- Moment Correlations of DEQ Dependency and Relatedness with MAAS Antenatal Attachment

Blatt Dependency

Blatt

Relatedness

MAAS Quality

MAAS

Intensity

MAAS Global

Personality(DEQ) Dependence (Immature)

X

.658*

-.194

.019

-.085

Relatedness (Mature)

X

X

-.241*

-.003

-.132

Note: N = 91

DEQ = Depressive Experiences Questionnaire Revised Scoring Method (Blatt et al., 1995) MAAS = Maternal Antenatal Attachment Scale * p < .05; *** p < .000

168

Table 46 Pearson Product Moment Correlations of MAAS Antenatal Attachment and Rude & Burnham’s Needy and Connectedness DEQ Scoring Method

Rude & Burnham Neediness

Rude & Burnham

Connectedness

MAAS Quality

MAAS

Intensity

MAAS Global

Personality(DEQ) Neediness (Unhealthy)

X

.377***

-.242*

.036

-.095

Connectedness (Healthy)

X

X

-.048

.041

-.004

Note: N = 91

DEQ = Depressive Experiences Questionnaire Revised Scoring Method (Rude & Burnham, 1995) * = p < .05; *** p < .000

169

170

Table 47 Linear Regression Analyses of Dependency and Self-Criticism Scores Predicting MAAS Global Attachment Score

95% CI

F (2, 88)

p

R²

Adj. R²

Standard Scoring

Dependency -1.32 to 1.96 Self-Criticism

-2.86 to .064

1.87

.16

.04

.019

McGill Scoring

Dependency -.08 to .08 Self-Criticism

-.15 to .002

1.86

.16

.04

.019

Blatt Subscales

Dependency -.37 to .13 Relatedness

-.21 to .22

.78

.46

.02

-.005

Rude & Burnham

Neediness -2.94 to 1.03 Connected

-1.44 to 2.01

.457

.63

.01

-.01

Note: N = 89

171

Table 48 Spearman’s rho Correlation of ORI Baby Narrative and Gestational Age (Weeks)

ORI Baby Narrative

Conceptual Level Length Ambivalence Conceptual Level X X X Length .127 X X Ambivalence -.170 .355** X Gestational Age (Weeks) -.114 .060 -.038

Note: N = 85

ORI = Object Relations Inventory ** = p = .001

172

Table 49 Comparison of Most Common Risk Factors

Baylor Sample Maloni Sample

Besser Sample

Gupton Sample*

N % N

% N

%

N %

Preterm Labor

40

43.95 41 46.06 X X X 20

Placenta Previa

3 3.29 7 7.86 X X X 20

Incompetent Cervix

29 31.87 6 6.74 X X X X

Cervical Abnormality

2 2.19 5 5.61 X X X X

Pregnancy-Induced Hypertension

18 19.78 3 3.3 X X X 18

Premature Rupture of Membranes

16 17.58 2 2.2 X X X 17

Other X X X 28.23 X X X 25

Diabetes

5 5.49 X X 146 100% X X

Total

91 ** 89 100 146 100% 105 100

Note: *Gupton did not include exact N per condition ** Percentages exceed 100% in view of dual or multiple diagnoses (Maloni et al., 2001; Besser et al., 2002; Gupton et al., 2001)

Table 50 Comparison of the ORI and MAAS Means and Standard Deviations from Two Samples

Baylor Sample

Israeli Sample

M SD M

SD

Object Representations (Mother)

Benevolent

4.11 1.54 4.62 1.20

Punitive

1.49 1.42 3.97 1.07

Ambitious

3.53 1.69 3.90 1.18

Ambivalent

1.83 1.30 2.61 1.32

Conceptual Level

5.17 1.22 5.34 2.08

Antenatal Attachment

Quality

46.01 3.48 45.21 4.24

Intensity

30.71 4.88 27.72 4.96

Note: Baylor Sample: Object Relations Inventory (ORI) N = 83

Maternal Antenatal Attachment Scale (MAAS) N = 91 Israeli Sample: N = 120 (Priel et al., 2001)

173

Table 51 Comparisons of Correlations for ORI Mother Narrative and Maternal Antenatal Attachment in Two Samples Baylor Sample

N = 83 Israeli Sample

N = 120 Quality Intensity Quality Intensity Object Representations (Mother)

Benevolent

.174 .045 .33*** .07

Punitive

-.020 -.154 -.23*** -.16

Ambitious

-.218 .043 .39*** .12

Ambivalent

-.130 -.168 -.29** -.11

Conceptual Level

.040 -.176 .42*** .19*

Note: **p <.01; ***p <.001 Israeli Sample (Priel et al., 2001)

174

APPENDIX A Baylor Internal Review Board Approval

175

APPENDIX B Letter of Consent

176

APPENDIX C

MEASURES

177

CENTER FOR EPIDEMIOLOGIC STUDIES—DEPRESSION SCALE (CES-D) Below is a list of some ways you may have felt or behaved. Please indicate how often you have felt this way during the last week by checking the appropriate space. Durin r

the

of a

days)

M

Time (5-7

1. I was bothered by things that usually don’t bother me.

0 1 3

2. I d ing; my appetite was poor.

0 1 2 3

3. I felt that I could not shake off the blues even with

0 1 2 3

4. I felt I was just as good as other people.

0 1 2 3

5. I had as do

0 1

6. I felt depressed.

0 1 2 3

7. I felt that everything I did was an effort.

0 1 2 3

8. I felt hopeful about the future.

0 1 2 3

9. I thou t my life had been a failure.

0 1 2 3

10. I f

0 1 2 3

11. My sleep was restless.

0 1 2 3

12. I was happy.

0 1 3

13. I talke

0 1 3

14. I f

0 1 2 3

15. People were unfriendly.

0 1 2 3

16. I enjoyed life.

0 1 2 3

17 I had

0 1

18. I felt sad. 0 1 2 3

19 felt liked me.

0 1

20. I could not get going. 0 1 2 3

g the past week: Rarely onone oftime (less than 1 day)

Some or alittlethe time (1-2 days)

Occasionally or

Moderate amount ofTime (3-4

ost or all of the

days)

2

id not feel like eat

help from my family or friends.

trouble keeping my mind on what I wing.

2 3

gh

elt fearful.

2

d less than usual.

elt lonely.

2

. crying spells. 2 3

. I that people dis 2 3

178

DEPRESSIVE EXPERIENCE UESTIONN E (DEQ)

Listed below er of statements concerning personal characteristics and traits. Read each item and decide u agree or disagree and to what extent. If you strongly agree

S Q AIR

are a numbwhether yo , circle7; if you

strongly disagree, circle 1; The midpoint, if you are neutral or undecided, is 4.

Strongly Strongly Disagree Agree

1. I set my personal goals and standards as high

as possible. 1 2 3 4 5 6 7

2. Without s pport from others who are close to me, I would be helpless. 1 2 3 4 5 6 7

3. I tend to isfied with my current plans and goals,

rat th 1 2 3 4 5 6 7

4. Sometimes I feel very big, and other times I feel v small. 2 3 5 6 7

5. When I am closely involved with someone, I never feel jealous. 1 2 3 4 5 6 7

6. I urgently need things that only other people

can provide. 1 2 3 4 5 6 7

7. I often find that I don't live up to my own standards or ideals. 1 2 3 4 5 6 7

8. I feel I am always making full use of my potential

abilities. 1 2 3 4 5 6 7 9. The lack of permanence in human relationships

doesn't bother me. 1 2 3 4 5 6 7 10. If I fail to live up to expectations, I feel unworthy. 1 2 3 4 5 6 7 11. Many times I feel helpless. 1 2 3 4 5 6 7 12. I seldom worry about being criticized for things

I have said or done. 1 2 3 4 5 6 7

13. There is a considerable difference between how I am now and how I would like to be. 1 2 3 4 5 6 7

14. I enjoy sharp competition with others. 1 2 3 4 5 6 7 15. I feel I have many responsibilities that I must meet. 1 2 3 4 5 6 7 16. There are times when I feel "empty" inside. 1 2 3 4 5 6 7 17. I tend not to be satisfied with what I have. 1 2 3 4 5 6 7 Copyright: Sidney J. Blatt, Ph.D., Joseph P. D'Afflitti, Ph.D., Donald M. Quinlan, Ph.D., 1979.

u

be sather an striving for higher goals.

ery 1 4

179

19. I become frightened when I feel alone. 1 2 3 4 5 6 7 20. I would feel like I'd be losing an important part

of myself if I lost a very close friend. 1 2 3 4 5 6 7

2 1 2 3 4 5 6 7

22. I have difficulty breaking off a relationship

1 2 3 4 5 6 7 23. I often think about the danger of losing someone

1 2 3 4 5 6 7

25.

1 2 3 4 5 6 7 26. I am not very concerned with how other people

1 2 3 4 5 6 7 27.

ejection. 1 2 3 4 5 6 7

29. It's important for my family that I succeed. 1 2 3 4 5 6 7

30. Often, I feel I have disappointed others. 1 2 3 4 5 6 7

lo . 1 2 3 4 5 6 7

t )

sts friend 1 2 3 4 5 6 7

lati nship. 1 2 3 4 5 6 7

are times when I feel extremely good about myself and other times

3 4 5 6 7

18. I don't care whether or not I live up to what other people expect of me. 1 2 3 4 5 6 7

1. People will accept me no matter how many mistakes

I have made.

that is making me unhappy.

who is close to me. 1 2 3 4 5 6 7

24. Other people have high expectations of me.

When I am with others, I tend to devalue or "undersell" myself.

respond to me.

No matter how close a relationship between two people is, there is always a large amount of uncertainty and conflict. 1 2 3 4 5 6 7

28. I am very sensitive to others for signs of r

31. If someone makes me angry, I let him (her) know

how I feel. 1 2 3 4 5 6 7

32. I constantly try, and very often go out of my way, to please or help people I am c se to

33. I have many inner resources (abilities, s rengths . 1 2 3 4 5 6 7

34. I find it very difficult to say "No" to the reque of s. 35. I never really feel secure in a close re o

. The way I feel about myself frequently varies: there36

when I see only the bad in me and feel like a total failure 1 2

180

7. Often, I feel threatened by change. 1 2 3 4 5 6 7

o

leave, I could still "go it alone." 1 2 3 4 5 6 7

her

.

gs e le

1 2 3 4 5 6 7 3. I often feel guilty. 1 2 3 4 5 6 7

4. I think of myself as a very complex person, one 1 2 3 4 5 6 7

5. I worry a lot about offending or hurting someone

1 2 3 4 5 6 7 6. Anger frightens me. 1 2 3 4 5 6 7

47.accomplished" that counts. 1 2 3 4 5 6 7

8. I feel good about myself whether I succeed or fail. 1 2 3 4 5 6 7

9. I can easily put my own feelings and problems aside,

problems of someone else. 1 2 3 4 5 6 7

50.would feel threatened that he (she) might leave me. 1 2 3 4 5 6 7

51. rtant responsibilities. 1 2 3 4 5 6 7

2. After a fight with a friend, I must make amends as

s .

1 2 3 4 5 6 7

3

38. Even if the person who is closest t me were to

39. One must continually work to gain love from anotperson: that is, love has to be earned 1 2 3 4 5 6 7

40. I am very sensitive to the effects my words or

actions have on the feelin of oth r peop . 1 2 3 4 5 6 7 41. I often blame myself for things I have done or

said to someone. 1 2 3 4 5 6 7 42. I am a very independent person.

4 4

who has "many sides."

4who is close to me.

4

It is not "who you are," but "what you have

4 4

and devote my complete attention to the feelings and

If someone I cared about became angry with me, I

I feel comfortable when I am given impo

5

soon as possible. 1 2 3 4 5 6 7 53. I have a difficult time accepting weaknesses in my elf 1 2 3 4 5 6 7 54. It is more important that I enjoy my work than it

is for me to have my work approved.

181

55. After an argument, I feel very lonely. 1 2 3 4 5 6 7

56. In my relationships with others, I am very concerned 1 2 3 4 5 6 7

57. rarely think about my family. 1 2 3 4 5 6 7

me vary:

when I feel all-loving towards that person. 1 2 3 4 5 6 7

59. those around me. 1 2 3 4 5 6 7

60. " l.

ys m

1 2 3 4 5 6 7 4. I tend to be very critical of myself. 1 2 3 4 5 6 7

65. l

ar o

about what they can give to me.

I

58. Very frequently, my feelings toward someone close tothere are times when I feel completely angry and other times

What I do and say has a very strong impact on

I sometimes feel that I am specia " 1 2 3 4 5 6 7

61. I grew up in an extremely close family. 1 2 3 4 5 6 7 62. I am very satisfied with m elf and my accomplish ents. 1 2 3 4 5 6 7 63. I want many things from someone I am close to.

6

Being alone doesn't bother me at a l. 1 2 3 4 5 6 7 66. I very frequently compare myself to stand ds or g als. 1 2 3 4 5 6 7

182

EDINBURGH POSTPARTUM DEPRESSION SCALE (EPDS)

Please circle the answ how you have felt over the past 7 days. er that best describes In the past 7 days: 1. ny sid of thin - I have been able to laugh and see the fun e gs 0 ys As much as I alwa could 1 Not quite so much now 2 Definitely not so much now 3 Not at all

2. I have looked forward with enjoyment to things - 0 As much as I ever did 1 Rather less than I used to 2 Definitely less than I used to 3 Hardly at all 3. I ha ent wrong - ve blamed myself unnecessarily when things w 0 No, not at all 1 Hardly ever 2 Yes, sometimes 3 Yes, very often 4. I have been anxious or worried for no good reason - 3 Yes, quite a lot 2 Yes, sometimes 1 No, not much 0 No, not at all 5. I have felt scared or panicky for no very good reason - 3 Yes, quite a lot 2 Yes, sometimes 1 No, not much 0 No, not at all

183

6. Things have been getting on top of me - 3 Yes, most of the time I haven't been able to cope at all 2 Yes, sometimes I haven't been coping as well as usual 1 No, most of the time I have coped quite well 0 No, I have been coping as well as ever

7. I have been so unhappy that I have had difficulty sleeping - 3 Yes, most of the time 2 Yes, sometimes 1 Not very often 0 No, not at all

8. I have felt sad or m erable - is 3 Yes, most of the time 2 Yes, quite often 1 Not very often 0 No, not at all

9. I have been so unhappy that I have been crying - 3 Yes, most of the time 2 Yes, quite often 1 Only occasionally 0 No, never

10. The thought of harming myself has occurred to me - 3 Yes, quite often 2 Sometimes 1 Hardly ever 0 Never

(J.L. Cox, J.M. Holden, R. Sagovsky, Department of Psychiatry, University of Edinburgh)

184

MATERNAL ANTENATAL ATTACHMENT SCALE (MAAS)

These questions are about your thoughts and feelings about the developing baby. Please tick one box only in answer to each question. 1) Over the past two weeks I have thought about, or been preoccupied with the baby inside me:

Almost all the time

Very fre uq ently

Frequently

Occasionally

Not at all 2) Over the past two weeks when I have spoken about, or thought about the baby inside me I got

emotional feelings which were:

Very weak or non-existent

Fairly weak

In between strong and weak

Fairly strong

Very strong 3) Over the past two weeks my feelings about the baby inside me have been:

Very positive

Mainly positive

Mixed positive and negative

Mainly negative

Very negative

185

4) Over the past two weeks I have had the desire to read about or get information about the developing baby. This desire is:

Very weak or non-existent

Fairly weak

Neither strong nor weak

Moderately strong

Very strong

5) O r tve he past two weeks I have been trying to picture in my mind what the developing baby

actually looks like in my womb:

Almost all the time

Very frequently

Frequently

Occasionally

Not at all 6) Over the past two weeks I think of the developing baby mostly as:

A real little person with special characteristics

A baby like any other baby

A human being

A living thing

A thing not yet really alive

186

7) Over the past two weeks I have felt that the baby inside me is dependent on me for its well-being:

Totally

A great deal

Moderately

Slightly

Not at all 8) Over the past two weeks I have found myself talking to my baby when I am alone:

Not at all

Occasionally

Frequently

Very frequently

Almost all the time I am alone 9) Over the past two weeks when I think about (or talk to) my baby inside me, my thoughts:

Are always tender and loving

Are mostly tender and loving

Are a mixture of both tenderness and irritation

Contain a fair bit of irritation

Contain a lot of irritation

187

10) The picture in my mind of what the baby at this stage actually looks like inside the womb is:

Very clear

Fairly clear

Fairly vague

Very vague

I have no idea at all 11) Over the past two weeks when I think about the baby inside me I get feelings which are:

Very sad

Moderately sad

A mixture of happiness and sadness

Moderately happy

Very happy 12) Some pregnant women sometimes get so irritated by the baby inside them that they feel like they want to hurt it or punish it:

I couldn’t imagine I would ever feel like this

I could imagine I might sometimes feel like this, but I never actually have

I have felt like this once or twice myself

I have occasionally felt like this myself

I have often felt like this myself

188

13) Over the past two weeks I have felt:

Very emotionally distant from my baby

Moderately emotionally distant from my baby

Not particularly emotionally close to my baby

Moderately close emotionally to my baby

Very close emotionally to my baby 14) Over the past two weeks I have taken care with what I eat to make sure the baby gets a good diet:

Not at all

Once or twice when I ate

Occasionally when I ate

Quite often when I ate

Every time I ate 15) When I first see my baby after the birth I expect I will feel:

Intense affection

Mostly affection

Dislike about one or two aspects of the baby

Dislike about quite a few aspects of the baby

Mostly dislike

189

16) When my baby is born I would like to hold the baby:

Immediately

After it has been wrapped in a blanket

After it has been washed

After a few hours for things to settle down

The next day 17) Over the past two weeks I have had dreams about the pregnancy or baby:

Not at all

Occasionally

Frequently

Very frequently

Almost every night 18) Over the past two weeks I have found myself feeling, or rubbing with my hand, the outside of my stomach where the baby is:

A lot of times each day

At least once per day

Occasionally

Once only

Not at all

190

19) If the pregnancy was lost at this time (due to miscarriage or other accidental event) without any pain or injury to myself, I expect I would feel:

Very pleased

Moderately pleased

Neutral (i.e. neither sad nor pleased, or mixed feelings)

Moderately sad

Very sad

Copywrite JT Condon Dept. Psychiatry Flinders Medical Centre, South Australia

191

Chart Review Participant number Obstetrician of record Birthdate Ethnicity Af Am Asian Caucasian Latino Other Marital Status Single Married Separated Divorced Widowed CohabitingTotal Pregnancies (Prior) Full Term (Prior) Premature (Prior) Abortions induced Abortions spontaneous Ectopics Multiple births (Prior) Living Stillborn List any interventions that have been initiated or ordered by the doctor: HOBEL RISK ASSESSMENT--PRENATAL yes no Moderate to severe toxemia 10 0 Chronic Hypertension 10 0 Moderate to severe renal disease 10 0 Severe heart disease, Class II-IV 10 0 History of eclampsia 5 0 History of pyelitis 5 0 Class I heart disease 5 0 Mild toxemia 5 0 Acute pyelonephritis 5 0 History of cystitis 1 0 Acute cystitis 1 0 History of toxemia 1 0 Diabetes > Class A-II 10 0 Previous endocrine ablation 10 0 Thyroid disease 5 0 Prediabetes (A-I) 5 0 Family history of diabetes 1 0

192

Previous fetal exchange transfusion for Rh 10 0 Previous stillbirth 10 0 Post-term > 42 weeks 10 0 Prevous premature infant 10 0 Previous neonatal death 10 0 Previous cesarean section 5 0 Habitual abortion 5 0 Infant > 10 pounds 5 0 Multiparity > 5 5 0 Epilepsy 5 0 Fetal anomalies 1 0 Uterine malformation 10 0 Incompetent cervix 10 0 Abnormal fetal position 10 0 Polyhydramnios or oligohydramnios 10 0 Small pelvis 5 0 Abnormal cervical cytology 10 0 Multiple pregnancy 10 0 Sickle cell disease 10 0 Age > 35 or < 15 5 0 Viral disease 5 0 Rh sensitization only 5 0 Positive serology 5 0 Severe anemia (< 9 Gm. Hgb) 5 0 Excessive use of drugs 5 0 History of TB or PPD > 10 mm. 5 0 Weight < 100 or > 200 pounds 5 0 Pulmonary disease 5 0 Flu syndrome (severe) 5 0 Vaginal spotting 5 0 Mild anemia (9-10.9 Gm. Hgb) 1 0 Smoking > 1 pack/day 1 0 Alcohol (moderate) 1 0 Emotional problem 1 0 Premature rupture of membrane (PROM) 5 0 Primary dysfunctional labor (PTL) 5 0 Placenta previa 10 0 Abruptio placentae 10 0

193

OBJECT RELATIONS INVENTORY (ORI)

DESCRIBE YOUR MOTHER.

194

OBJECT RELATIONS INVENTORY (ORI)

DESCRIBE THE BABY YOU ARE CARRYING.

195

BIBLIOGRAPHY

Diagnostic and Statistical Manual of Mental Disorders—IV--TR (2000).

Washington, DC: American Psychiatric Association.

Ainsworth, M. D. S. (1968). Citation for the G. Stanley hall Award to John

Bowlby. Unpublished manuscript.

Ainsworth, M. D. S., Bell, S. M., & Stayton, D. J. (1974). Infant-mother

attachment and social development: "Socialization" as a product of reciprocal

responsiveness to signals. In M. P. M. Richards (Ed.), The integration of a child into a

social world (pp. 99-135). New York: Cambridge University Press

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of

attachment: A psychological study of the Strange Situation. Hillsdale, NJ: Erlbaum.

Ainsworth, M. D. S. & Marvin, R. S. (1995). On the shaping of attachment theory

and research: An interview with Mary D. S. Ainsworth (Fall 1994). Monographs of the

Society for Research in Child Development, 60, -21.

Angyal, A. (1941). Foundations for a science of personality. New York: Viking

Press.

Atkinson, L., Goldberg, S., Raval, V., Pederson, D., Benoit, D., Moran, G. et al.

(2005). On the Relation Between Maternal State of Mind and Sensitivity in the Prediction

of Infant Attachment Security. Developmental Psychology, 41, 42-53.

196

Austin, M. P. & Lumley, J. (2003). Antenatal screening for postnatal depression:

A systematic review. Acta Psychiatrica Scandinavia, 107, 10-17.

Bacchiochi, J. R., Bagby, R. M., Cristi, C., & Watson, J. (2003). Validation of

connectedness and neediness as dimensions of the dependency construct. Cognitive

Therapy & Research, 27, 233-242.

Bagby, R. M., Parker, J. D., Joffe, R. T., & Buis, T. (1994). Reconstruction and

validation of the Depressive Experiences Questionnaire. Assessment, 1, 59-68.

Bakan, D. (1966). The duality of human existence: An essay on psychology and

religion. Chicago: Rand McNally.

Balint, M. (1959). Thrills and regressions. London: Hogarth Press.

Bartholomew, K. & Horowitz, L. M. (1991). Attachment styles among young

adults: A test of a four-category model. Journal of Personality and Social Psychology,

61, 226-243.

Bartholomew, K. & Shaver, P. (1998). Methods of assessing adult attachment: Do

they converge? In J. A. Simpson & W. S. Roles (Eds.), Attachment Theory and Close

Relationships (pp. 25-45). New York: Guilford

Beck, A. T. (1983). Cognitive therapy of depression: New perspectives. In P. J.

Clayton & J. E. Barrett (Eds.), Treatment of depression: Old controversies and new

approaches. New York: Raven Press

197

Beck, A. T., Epstein, N., Harrison, R. P., and Emery, G. (1983). Development of

the sociotropy autonomy scale: A measure of personality factors in psychopathology.

Unpublished manuscript.

Beck, C. T. (1999a). Available instruments for research on prenatal attachment

and adaptation to pregnancy. MCN, American Journal of Maternal Child Nursing, 24, 25-

32.

Beck, C. T. (1999c). Available instruments for research on prenatal attachment

and adaptation to pregnancy. MCN, American Journal of Maternal Child Nursing, 24, 25-

32.

Beck, C. T. (1999b). Available instruments for research on prenatal attachment

and adaptation to pregnancy. MCN, American Journal of Maternal Child Nursing, 24, 25-

32.

Beeghly, M., Weinberg, M., Olson, K., Kernan, H., Riley, J., & Tronick, E.

(2002). Stability and change in level of maternal depressive symptomatology during the

first postpartum year. Journal of Affective Disorders, 71, 169.

Benedek, T. (1959). Parenthood as a developmental phase: A contribution to the

libido theory. Journal of the American Psychoanalytic Association, 7, 389-417.

Benedek, T. (1958). Psychological aspects of pregnancy and parent-child

relationships. In S. Liebman (Ed.), (pp. 1-16). Oxford, England: Lippincott.

198

Benoit, D., Parker, K. C., & Zeanah, C. H. (1997). Mothers' representations of

their infants assessed prenatally: stability and association with infants' attachment

classifications. Journal of Child Psychology & Psychiatry & Allied Disciplines,

38(3):307-13.

Benoit, D. & Parker, K. C. H. (1994). Stability and transmission of attachment

across three generations. Child Development, 65, 1444-1456.

Besser, A. & Priel, B. (2003a). A multisource approach to self-critical

vulnerability to depression: The moderating role of attachment. Journal of Personality,

71, 515-555.

Besser, A., Flett, G. L., & Davis, R. A. (2003). Self-criticism, dependency,

silencing the self, and loneliness: A test of a mediational model. Personality & Individual

Differences, 35, 1735-1752.

Besser, A. & Priel, B. (2003b). Trait vulnerability and coping strategies in the

transition to motherhood. Current Psychology: Developmental, Learning, Personality,

Social, 22, 57-72.

Besser, A., Priel, B., & Wiznitzer, A. (2002). Childbearing depressive

symptomatology in high-risk pregnancies: The roles of working models and social

support. Personal Relationships, 9, 395-413.

199

Bibring, G. L. (1959). Some considerations of the psychological processes in

pregnancy. Psychoanalytic Study of the Child, 14, 113-121.

Bibring, G. L., Dwyer, T. F., Huntington, D. S., & Valenstein, A. F. (1961). A

study of the psychological processes in pregnancy and of the earliest mother-child

relationship. Psychoanalytic Study of the Child, 16, 9-72.

Blatt, S., Auerbach, J. S., & Lindgren, K. (1997). Mental representations in

personality development, psychopathology, and the therapeutic process. Review of

General Psychology, 1, 351-374.

Blatt, S., Chevron, S. E., Quinlan, D. M., Schaffer, C. E., and Wein, S. (1992a).

The assessment of qualitative and structural dimensions of object representations.

Unpublished manuscript.

Blatt, S. J. (1974). Levels of object representation in anaclitic and introjective

depression. The Psychoanalytic Study of the Child, 24, 107-157.

Blatt, S. J., Auerbach, J. S., & Levy, K. N. (1997). Mental representations in

personality development, psychopathology, and the therapeutic process. Review of

General Psychology, 1, 351-374.

Blatt, S. J., D'Affliti, J. P., & Quinlan, D. M. (1976). Experiences of depression in

normal young adults. Journal of Abnormal Psychology, 85, 383-389.

200

Blatt, S. J., Shahar, G., & Zuroff, D. C. (2001). Anaclitic (sociotropic) and

introjective (autonomous) dimensions. Psychotherapy, 38, 449-454.

Blatt, S. J. & Zuroff, D. C. (1992b). Interpersonal relatedness and self-definition:

Two prototypes for depression. Clinical Psychology Review, 12, 527-562.

Blatt, S. J. (2004). Measurement of anaclitic and introjective depressive

experiences. In Experiences of depression: Theoretical, clinical, and research

perspectives (pp. 91-123). Washington, DC: American Psychological Association

Blatt, S. J., Schaffer, C. E., Bers, S. A., & Quinlan, D. M. (1992). Psychometric

properties of the Depressive Experiences Questionnaire for adolescents. Journal of

Personality Assessment, 59, 82-98.

Blatt, S. J., Zohar, A. H., Quinlan, D. M., & Zuroff, D. C. (1995). Subscales

within the dependency factor of the Depressive Experiences Questionnaire. Journal of

Personality Assessment, 64, 319-339.

Blumberg, N. L. (1980). Effects of neonatal risk, maternal attitude, and cognitive

style on early postpartum adjustment. Journal of Abnormal Psychology, 89, 139-150.

Bornstein, R. F., Galley, D. J., & Leone, D. R. (1986). Parental representations

and orality. Journal of Personality Assessment, 50, 80-89.

Bowlby, J. (1969). Attachment and Loss Volume I: Attachment. New York: Basic

Books, Inc.

201

Bowlby, J. (1973). Attachment and Loss Volume II: Separation: Anxiety and

Anger. New York: Basic Books, Inc.

Bowlby, J. (1980). Attachment and Loss Volume III: Loss, Sadness, and

Depression. New York: Basic Books, Inc.

Bowlby, J. (1951). Maternal care and mental health. Bulletin of the World Health

Organization, 3, 355-533.

Bowlby, J. (1986). The nature of the child's tie to his mother. In P. Buckley (Ed.),

Essential papers on object relations (pp. 153-199). New York: New York University

Press. (Original work published 1958).

Boyce, P. & Condon, J. (2000). Traumatic childbirth and the role of debriefing. In

J. P. Wilson & B. Raphael (Eds.), Psychological debriefing: Theory, practice and

evidence (pp. 272-280). New York: Cambridge University Press.

Bretherton, I. (1992). The Origins of Attachment Theory: John Bowlby and Mary

Ainsworth. Developmental Psychology, 28, 759-775.

Bretherton, I. (1985). Attachment theory: Retrospect and prospect. In I.

Bretherton & E. Waters (Eds.), Growing Points of Attachment Theory and Research.

Monographs of the Society for Research in Child Development (pp. 3-35).

Brisch, K. H. (2002). Treating attachment disorders. New York: Guilford Press.

202

Bushnell, I. W., Sai, F., & Mullin, J. T. (1989). Neonatal recognition of the

mother's face. British Journal of Developmental Psychology, 7, 3-15.

Cannella, B. L. (2005). Maternal-fetal attachment: an integrative review. Journal

of Advanced Nursing.50(1):60-8.

Carson, K. & Virden, S. (1984). Can prenatal teaching promote maternal

attachment? Practicing nurses test Carter-Jessop's prenatal attachment intervention.

Health Care for Women International, 5(5-6):355-69.

Carter-Jessop, L. (1981). Promoting maternal attachment through prenatal

intervention. MCN, American Journal of Maternal Child Nursing, 6, 107-112.

Cohen, R. L. (1979). Maladaption to pregnancy. Seminars in Perinatology, 3, 15-

24.

Condon, J. T. (1993). The assessment of antenatal emotional attachment:

Development of a questionnaire instrument. British Journal of Medical Psychology, 66,

167-183.

Condon, J. T. (2005). Personal Communication.

Condon, J. T. & Corkindale, C. (1997). The correlates of antenatal attachment in

pregnant women. British Journal of Medical Psychology, 70, 359-372.

203

Condon, J. T. (1986). Management of established pathological grief reaction after

stillbirth. American Journal of Psychiatry, 143, 987-992.

Condon, J. T. & Corkindale, C. J. (1998). The assessment of parent-to-infant

attachment: Development of a self-report questionnaire instrument. Journal of

Reproductive and Infant Psychology, 16, -76.

Cox, J. & Holden, J. (2003a). Perinatal mental health: A guide to the Edinburgh

Postnatal Depression Scale (EPDS). London: Royal College of Psychiatrists.

Cox, J. & Holden, J. (2003b). The origins and development of the Edinburgh

Postnatal Depression Scale. In Perinatal Mental Health (pp. 15-20). London: Royal

College of Psychiatrists.

Cranley, M. S. (1992). A critical review of prenatal attachment research.

Scholarly Inquiry for Nursing Practice, 6, 23-26.

Cranley, M. S. (1979). The impact of perceived stress and social support on

maternal-fetal attachment in the third trimester. University of Wisconsin, Madison, WI.

Cranley, M. S. (1981). Development of a tool for the measurement of maternal

attachment during pregnancy. Nursing Research, 30, 281-284.

Curry, M. A. (1987). Maternal behavior of hospitalized pregnant women. Journal

of Psychosomatic Obstetrics & Gynecology, 7, 165-182.

204

Dawson, G., Klinger, L. G., Panagiotides, H., Hill, D., & Spieker, S. (1992).

Frontal lobe activity and affective behavior of infants of mothers with depressive

symptoms. Child Development, 63, 725-737.

DeCasper, A. J. & Fifer, W. P. (1980). Of human bonding: Newborns prefer their

mothers' voices. Science, 208, 1174-1176.

Dennis, C. L. (2004). Preventing postpartum depression part II: A critical review

of nonbiological interventions. Canadian Journal of Psychiatry, 49, 526-538.

Deutch, H. (1945). The psychology of women. New York: Grune & Stratton.

Diamond, D., Blatt, S. J., Stayner, D. A., and Kaslow, N. (1995). Differentiation-

relatedness of self and object representations. Unpublished manuscript.

Doan, H. M. & Zimerman, A. (2003). Conceptualizing prenatal attachment:

Toward a multidimensional view. Journal of Prenatal & Perinatal Psychology & Health,

18, 109-129.

Feldman, R. & Blatt, S. J. (1996). Precursors of relatedness and self-definition in

mother-infant interaction. In J. M. Masling & R. F. Bornstein (Eds.), Psychoanalytic

perspectives on developmental psychology (pp. 1-42). Washington, D.C.: American

Psychological Association.

205

Fifer, W. P. (2002). The fetus, the newborn, and the mother's voice. In J. Gomes-

Pedro, J. K. Nugent, J. G. Young, & T. B. Brazelton (Eds.), The infant and the family in

the twenty-first century (pp. 79-85). New York: Brunner-Routledge.

Fishler, P. H., Sperling, M. B., & Carr, A. C. (1990). Assessment of adult

relatedness: A review of empirical findings from object relations and attachment theories.

Journal of Personality Assessment, 55, 520.

Fonagy, P. (2001b). Attachment theory and psychoanalysis. New York: Other

Press.

Fonagy, P. (2001a). Introduction to attachment theory. In Attachment Theory and

Psychoanalysis (pp. 5-18). New York: Other Press.

Fonagy, P., Steele, H., & Steele, M. (1991). Maternal representations of

attachment during pregnancy predict the organization of infant-mother attachment at one

year of age. Child Development, 62, 891-905.

Fowles, E. (1996). Relationships among prenatal maternal attachment, presence

of postnatal depressive symptoms, and maternal role attainment. Journal of Society of

Perinatal Nursing, 1, 75-82.

Freud, S. (1955). The psychogenesis of a case of homosexuality in a woman

(1920). In J. Strachey (Ed.), The standard edition of the complete psychological works of

Sigmund Freud (pp. 145-172). London: Hogarth Press. (Original work published 1920.)

206

Frost, M. & Condon, J. T. (1996). The psychological sequelae of miscarriage: A

critical review of the literature. Australian and New Zealand Journal of Psychiatry, 30,

54-62.

Fuller, J. R. (1990). Early patterns of maternal attachment. Health Care for

Women International, 11, 433-446.

Gaffney, K. F. (1989). Maternal-fetal attachment in relation to self-concept and

anxiety. Journal of Perinatology, 13, 453-460.

Gaynes, B. N., Gavin, N., Meltzer-Brody, S., Lohr, K. N., Swinson, T.,

Gartlehner, G. et al. (2005). Perinatal depression: Prevalence, screening accuracy and

screening outcomes (Evidence Report/Technology Assessment No. 119). Rockville, MD:

Agency for Healthcare Research and Quality.

George, C., Kaplan, N., and Main, M. (1985). The attachment interview for

adults. Unpublished manuscript.

Grace, J. T. (1989). Development of maternal-fetal attachment during pregnancy.

Nursing Research, 38, 228-232.

Greenberg, J. R. & Mitchell, S. A. (1983). Object relations in psychoanalytic

theory. Cambridge, MA: Harvard University Press.

207

Griffin, D. W. & Bartholomew, K. (1994). Models of the self and other:

Fundamental dimensions underlying measures of adult attachment. Journal of

Personality and Social Psychology, 67, 430-445.

Gupton, A., Heaman, M., & Cheung, L. W. (2001). Complicated and

uncomplicated pregnancies: women's perception of risk. JOGNN: Journal of Obstetric,

Gynecologic, and Neonatal Nursing, 30, 192-201.

Hazan, C. & Shaver, P. (1987). Romantic love conceptualized as an attachment

process. Journal of Personality and Social Psychology, 52, 511-524.

Heaman, M. (1998). Psychosocial impact of high-risk pregnancy: Hospital and

home care. Clinical Obstetrics and Gynecology, 41, 626-639.

Heaman, M. (1992). Stressful life events, social support, and mood disturbance in

hospitalized and non-hospitalized women with pregnancy-induced hypertension.

Canadian Journal of Nursing Research, 24, 23-37.

Heaman, M., Beaton, J., Gupton, A., & Sloan, J. (1992). A comparison of

childbirth expectations in high-risk and low-risk pregnant women. Clinical Nursing

Research, 1, 252-265.

Hobel, C. J., Hyvarinen, M. A., Okada, D. M., & Oh, W. (1973). Prenatal and

intrapartum high-risk screening: I. Prediction of the high-risk neonate. American Journal

of Obstetrics and Gynecology, 117, 1-9.

208

Hobel, C. J., Youkeles, L., & Forsythe, A. (1979). Prenatal and intrapartum high-

risk screening: II. Prediction of prematurity. American Journal of Obstetrics and

Gynecology, 135, 1051-1056.

Horney, K. (1945). Our Inner Conflicts. New York: Norton.

Kemp, V. H. & Page, C. (1987). Maternal self-esteem and prenatal attachment in

high-risk pregnancy. Maternal-Child Nursing Journal.16(3):195-206.

Kennell, J. H., Slyter, H., & Klaus, M. H. (1970). The mourning response of

parents to the death of a newborn infant. New England Journal of Medicine, 283(7):344-

9.

Klaus, M. H., Jerauld, R., Kreger, N. C., McAlpine, W., Steffa, M., & Kennel, J.

H. (1972). Maternal attachment: Importance of the first post-partum days. New England

Journal of Medicine, 286(9):460-3.

Kobak, R. R. & Sceery, A. (1988). Attachment in late adolescence: Working

models, affect regulation, and representations of self and others. Child Development, 59,

135-146.

Koestner, R., Zuroff, D. C., & Powers, T. A. (1991). Family origins of adolescent

self-criticism and its continuity into adulthood. Journal of Abnormal Psychology, 100,

191-197.

209

Koniak-Griffin, D. (1988). The relationship between social support, self-esteem,

and maternal-fetal attachment in adolescents. Research in Nursing & Health, 11(4):269-

78.

Krohn, A. & Mayman, M. (1974). Object representations in dreams and projective

tests. Bulletin of the Menninger Clinic, 38, 445-466.

Kubler-Ross, E. (1969). On death and dying. New York: Macmillan.

Kurki, T., Hiilesmaa, V., Raitasalo, R., Mattila, H., & Ylikorkala, O. (2000).

Depression and anxiety in early pregnancy and risk for preeclampsia. Obstetrics and

Gynecology, 95, 487-490.

Lang, S. S. (2005). Unwed mothers' prospects for marrying well, or at all, are

greatly diminished, Cornell study finds. Cornell News Service [On-line]. Available:

http://www.news.cornell.edu/stories/Sept05/moms.marriage.ssl.html

Laxton-Kane, M. & Slade, P. (2002). The role of maternal prenatal attachment in

a woman's experience of pregnancy and implications for the process of care. Journal of

Reproductive and Infant Psychology, 20, 253-266.

Leichtentritt, R. D., Blumenthal, N., Elyassi, A., & Rotmensch, S. (2005). High

risk pregnancy and hospitalization: The women's voices. Health and Social Work, 30, 39-

47.

210

Leifer, M. (1980). Psychological effects of motherhood: A study of first

pregnancy. New York: Praeger.

Leifer, M. (1977). Psychological changes accompanying pregnancy and

motherhood. Genetic Psychology Monographs, 95, 55-96.

Lerum, C. W. & LoBiondo-Wood, G. (1989). The relationship of maternal age,

quickening, and physical symptoms of pregnancy to the development of maternal-fetal

attachment. Birth, 16, 13-17.

Levine, L. V., Tuber, S. B., Slade, A., & Ward, M. J. (1991). Mothers' mental

representations and their relationship to mother-infant attachment. Bulletin of the

Menninger Clinic, 55, 454-470.

Lindgren, K. (2001). Relationships among maternal-fetal attachment, prenatal

depression, and health practices in pregnancy. Research in Nursing and Health, 24, 203-

217.

Lindgren, K. (2003). A comparison of pregnancy health practices of women in

inner-city and small urban communities. Journal of Obstetric, Gynecologic, and

Neonatal Nursing, 32, 313-321.

LoBiondo-Wood, G. & Vito-O'Rourke, K. (1990). The prenatal maternal

attachment scale: A methodological study. Paper presented at NAACOG's Research

Conference: Denver, CO.

211

Logghe, H. & Walker, J. J. (2004). Towards improved neonatal outcome: Future

strategies. Seminars in Fetal & Neonatal Medicine, 9, 491-498.

Lorensen, M., Wilson, M. E., & White, M. A. (2004). Norwegian families:

transition to parenthood. Health Care for Women International, 25, 334-348.

Lumley, J. (2003). Defining the problem: The epidemiology of preterm birth.

BJOG: An International Journal of Obstetrics and Gynecology, 110, 3-7.

Lumley, J. M. (1972). The development of maternal-foetal bonding in first

pregnancy. Basle: Karger.

Lumley, J. M. (1980). Through a glass darkly: Ultrasound and prenatal bonding.

Birth, 17, 214-217.

Lumley, J. M. (1982). Attitudes to the fetus among primigravidae. Australian

Pediatric Journal, 18, 106-109.

Main, M. & Goldwyn, R. (1984). Predicting rejection of her infant from mother's

representation of her own experience: Implications for the abused-abusing

intergenerational cycle. Child abuse and neglect, 8, 203-217.

Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and

adulthood: A move to the level of representation. Monographs of the Society for

Research in Child Development, 50, 66-104.

212

Maloni, J. A., Brezinski-Tomasi, J. E., & Johnson, L. A. (2001). Antepartum bed

rest: effect upon the family. JOGNN: Journal of Obstetric, Gynecologic, and Neonatal

Nursing, 30, 165-173.

Maloni, J. A., Kane, J. H., Suen, L., & Wang, K. K. (2002). Dysphoria among

high-risk pregnant hospitalized women on bed rest: a longitudinal study. Nursing

Research, 51, 92-99.

Maloni, J. A. & Kasper, C. E. (1991). Physical and psychosocial effects of

antepartum hospital bedrest: a review of the literature. Image: Journal of Nursing

Scholarship, 23, 187-192.

Maloni, J. A. & Park, S. (2005). Postpartum symptoms after antepartum bed rest.

JOGNN: Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34, 163-171.

Maloni, J. A., Park, S., Anthony, M. K., & Musil, C. M. (2005). Measurement of

antepartum depressive symptoms during high-risk pregnancy. Research in Nursing &

Health, 28, 16-26.

Marcus, S. M., Flynn, H. A., Blow, F. C., & Barry, K. L. (2003). Depressive

symptoms among pregnant women screened in obstetrics settings. Journal of Women's

Health, 12, 373-380.

213

McBride, C., Zuroff, D. C., Bacchiochi, J., & Bagby, R. M. (2006). Depressive

experiences questionnaire: Does it measure maladaptive and adaptive forms of

dependency? Social Behavior and Personality, 34, 1-16.

McCranie, E. W. & Bass, J. D. (1984). Childhood family antecedents of

dependency and self-criticism: Implications for depression. Journal of Abnormal

Psychology, 93, 3-8.

Mercer, R. T. (1977). Nursing Care for Parents at Risk. Thorofare, N.J.: C.B.

Slack.

Mercer, R. T. (1983). Parent-infant attachment. In K. Kowalski & B. Jennings

(Eds.), Women's Health, Vol. 2 (pp. 17-42). New York: Grune & Stratton.

Mercer, R. T. & Ferketich, S. L. (1988). Stress and social support as predictors of

anxiety and depression during pregnancy. Advances in Nursing Science, 10, 26-39.

Mercer, R. T., Ferketich, S., DeJoseph, J., May, K., & Sollid, D. (1988). Effect of

stress on family functioning during pregnancy. Nursing Research, 37, 268-275.

Mercer, R. T., Ferketich, S., May, K., DeJoseph, J., & Sollid, D. (1988). Further

exploration of maternal and paternal fetal attachment. Research in Nursing & Health, 11,

269-278.

Mercer, R. T. & Ferketich, S. L. (1994). Predictors of maternal role competence

by risk status. Nursing Research, 43, 38-43.

214

Mikhail, M. S., Freda, M. C., Merkatz, R. B., Polizzotto, R., Mazloom, E., &

Merkatz, I. R. (1991). The effect of fetal movement counting on maternal attachment to

fetus. American Journal of Obstetrics & Gynecology, 165, 988-991.

Mikulincer, M. & Florian, V. (1999). Maternal-fetal bonding, coping strategies,

and mental health during pregnancy--the contribution of attachment style. Journal of

Social and Clinical Psychology, 18, 255-276.

Millon, T. (1987). Manual for the MCMI-2. Minneapolis, MN: National

Computer Systems.

Moncher, F. J. (1996). The relationship of maternal adult attachment style and

risk of physical child abuse. Journal of Interpersonal Violence, 11, 335-350.

Morrison, T. L., Urquiza, A. J., & Goodlin-Jones, B. (1998). Depressive

experience and romantic relationships in young adulthood. Psychological Reports, 82,

339-349.

Muller, M. E. (1996). Prenatal and postnatal attachment: a modest correlation.

Journal of Obstetric, Gynecologic, & Neonatal Nursing, 25, 161-166.

Muller, M. E. (1992). A critical review of prenatal attachment research. Scholarly

Inquiry for Nursing Practice, 6, 5-22.

Muller, M. E. & Ferketich, S. (1993). Factor analysis of the Maternal Fetal

Attachment Scale. Nursing Research, 42, 144-147.

215

Muller, M. E. & Ferketich, S. (1992). Assessing the validity of the dimensions of

prenatal attachment. Maternal-Child Nursing Journal., 20, 1-10.

Muller, M. E. (1990). The development and testing of the Muller Prenatal

Attachment Inventory.

Muller, M. E. (1993). Development of the prenatal attachment inventory. Western

Journal of Nursing Research, 15, 199-215.

Murray, L. (1992). The impact of postnatal depression on infant development.

Journal of Child Psychology and Psychiatry, 33, 543-561.

Parker, G., Tulping, H., & Brown, L. B. (1979). A parental attachment

instrument. British Journal of Medical Psychology, 52, 1-10.

Penticuff, J. H. (1982). Psychologic implications in high-risk pregnancy. Nursing

Clinics of North America.17(1):69-78.

Piontelli, A. (1987). Infant observation from before birth. International Journal of

Psychoanalysis, 68, 453-463.

Piontelli, A. (1988). Prenatal life reflected in the analysis of a psychotic girl at age

two. Psychoanalytic Study of the Child, 38, 337-351.

Pollock, P. H. & Percy, A. (1999b). Maternal antenatal attachment style and

potential fetal abuse. Child Abuse & Neglect, 23, 1345-1357.

216

Pollock, P. H. & Percy, A. (1999). Maternal antenatal attachment style and

potential fetal abuse. Child Abuse & Neglect, 23, 1345-1357.

Porter, R. H., Winberg, J., & Varendi, H. (2005). Prenatal Preparation for Early

Postnatal Olfactory Learning. In B. Hopkins & S. P. Johnson (Eds.), Prenatal

development of postnatal functions (pp. 103-129). Westport, CT: Praeger

Publishers/Greenwood Publishing Group, Inc.

Priel, B. & Besser, A. (2001). Bridging the gap between attachment and object

relations theories: A study of the transition to motherhood. British Journal of Medical

Psychology, 74, 85-100.

Priel, B. & Besser, A. (1999). Vulnerability to postpartum depressive

symptomatology: Dependency, self-criticism and the moderating role of antenatal

attachment. Journal of Social and Clinical Psychology, 18, 240-253.

Priel, B. & Besser, A. (2000a). Dependency and self-criticism among first-time

mothers: The roles of global and specific support. Journal of Social and Clinical

Psychology, 19, 437-450.

Priel, B. & Besser, A. (2000b). Adult attachment styles, early relationships,

antenatal attachment, and perceptions of infant temperament: A study of first-time

mothers.

217

Reading, A. E., Cox, D. N., Sledmere, C. M., & Campbell, S. (1984).

Psychological changes over the course of pregnancy: A study of attitudes toward the

futus/neonate. Health Psychology, 3, 211-221.

Righetti, P. L., Dell'Avanzo, M., Grigio, M., & Nicolini, U. (2005).

Maternal/paternal antenatal attachment and fourth-dimensional ultrasound technique: a

preliminary report. British Journal of Psychology, 96, 129-137.

Rubin, R. (1967a). Attainment of the maternal role: Part I. Processes. Nursing

Research, 16, 237-245.

Rubin, R. (1967b). Attainment of the maternal role: Part II. Models and referrants.

Nursing Research, 16, 342-346.

Rubin, R. (1975). Maternal tasks in pregnancy. Maternal Child Nursing Journal,

4, 143-153.

Rude, S. S. & Burham, B. L. (1995). Connectedness and neediness: Factors of the

DEQ and SAS dependency scales. Cognitive Therapy & Research, 19, 323-340.

Santor, D. A., Zuroff, D. C., & Fielding, A. (1997a). Analysis and revision of the

Depressive Experiences Questionnaire: Examining scale performance as a function of

scale length. Journal of Personality Assessment, 69, 163.

218

Santor, D. A., Zuroff, D. C., Mongrain, M., & Fielding, A. (1997b). Validating

the McGill revision of the Depressive Experiences Questionnaire. Journal of Personality

Assessment, 69, 164-182.

Senn, M. J. E. (1977). Interview with John Bowlby. Unpublished manuscript.

Shieh, C., Kravitz, M., & Wang, H. H. (2001). What do we know about maternal-

fetal attachment? Kaohsiung Journal of Medical Science, 17, 448-454.

Shor, J. & Sanville, J. (1978). Illusions in loving: A psychoanalytic approach to

intimacy and autonomy. Los Angelis: Double Helix.

Siddiqui, A. & Hagglof, B. (2000). Does maternal prenatal attachment predict

postnatal mother-infant interaction? Early Human Development, 59, 13-25.

Siddiqui, A., Hagglof, B., & Eisemann, M. (1999). An exploration of prenatal

attachment in Swedish expectant women. Journal of Reproductive and Infant

Psychology, 17, 369-380.

Siddiqui, A., Hagglof, B., & Eisemann, M. (2000). Own memories of upbringing

as a determinant of prenatal attachment in expectant women. Journal of Reproductive

and Infant Psychology, 18, 67-74.

Sorenson, D. S. & Schuelke, P. (1999). Fantasies of the unborn among pregnant

women. The American Journal of Maternal/Child Nursing, 24, 92-97.

219

Sroufe, L. A. & Waters, E. (1977). Attachment as an organizational construct.

Child Development, 48, 1184-1199.

Stainton, M. C. (1990). Parents' awareness of their unborn infant in the third

trimester. Birth, 17(2):92-6.

Steinberg, S. I. & Bellavance, F. (1999). Characteristics and treatment of women

with antenatal and postpartum depression. International Journal of Psychiatry in

Medicine, 29, 209-233.

Unauthored (1999). NICHD Early Child Care Research Network. Developmental

Psychology, 35, 1297.

van Ijzendoorn, M. H. (1995). Adult attachment representations, parental

responsiveness, and infant attachment: A meta-analysis on the predictive validity of the

Adult Attachment Interview. Psychological Bulletin, 117, 387-403.

Waters, E. (2005). Personal Communication.

Weaver, R. H. & Cranley, M. S. (1983). An exploration of paternal-fetal

attachment behavior. Nursing Research, 32, 68-72.

Whiffen, V. E. & Johnson, S. M. (2006). An attachment theory framework for the

treatment of childbearing depression. Clinical Psychology: Science and Practice, 5, 478-

492.

220

White, M. & Ritchie, J. (1984). Psychological stressors in antepartum

hospitalization: Reports from pregnant women. Maternal-Child Nursing Journal, 13, 47-

56.

White, M. A., Wilson, M. E., Elander, G., & Persson, B. (1999). The Swedish

family: Transition to parenthood. Journal of Advanced Nursing, 13, 171-176.

Wood, N. S., Marlow, N., Costeloe, K., Gibson, A. T., & Wilkinson, A. R.

(2000). Neurological and developmental disability after extremely preterm birth. New

England Journal of Medicine, 343, 378-384.

Zeanah, C. H., Benoit, D., Barton, M., Regan, C., Hirshberg, L. M., & Lipsitt, L.

P. (1993). Representations of attachment in mothers and their one-year-old infants.

Journal of the American Academy of Child & Adolescent Psychiatry, 32(2):278-86.

Zeanah, C. H., Carr, S., & Wolk, S. (1990). Fetal movements and the imagined

baby of pregnancy: Are they related? Journal of Reproductive and Infant Psychology, 8,

23-26.

Zimerman, A. & Doan, H. M. (2003). Prenatal attachment and other feelings and

thoughts during pregnancy in three groups of pregnant women. Journal of Prenatal &

Perinatal Psychology & Health, 18 (2), 131-148.

Zuroff, D. C. & Fitzpatrick, D. K. (1995). Depressive personality styles:

Implications for adult attachment. Personality and Individual Differences, 18, 253-265.

221

Zuroff, D. C., Igreja, I., & Mongrain, M. (1990). Dysfunctional attitudes,

dependency, and self-criticism as predictors of depressive mood states: A 12-month

longitudinal study. Cognitive Therapy & Research, 14, 326.

Zuroff, D. C., Quinlan, D. M., & Blatt, S. J. (1990). Psychometric properties of

the Depressive Experiences Questionnaire in a college population. Journal of Personality

Assessment, 55, 65-72.

222

VITAE Anna Rachel Brandon was born in Cleveland, Ohio, to Ronald and Barbara Coleman. She

completed High School in Brownwood, Texas in 1973. She married and relocated to California

where her daughters, Rachel and Sarah, were born. She returned to Texas in 1981, living in San

Antonio, where her son, David, was born. In 1991, she relocated her textile sales agency to the

Dallas International Apparel Mart. She began attending Mountain View College part-time,

completing an Associate of Arts degree in Business in 1999. She was accepted to Southern

Methodist University and, in 2001, she graduated Summa cum laude with dual degrees in

Business Administration and Psychology. In August 2002, she entered the Graduate School of

Biomedical Sciences at the University of Texas Health Science Center at Dallas.

Permanent Address: 3211 Rosedale Ave. Dallas, TX 75205